Presenting Problem - we are currently auditing ER visits

Michele1229

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Hello -
We are having a debate in my office about the nature of the presenting problem. We are having conflicting views on this and we are currently auditing ER visits. In relation to the table of risk... do you look at the presenting symptom or do you look at what was found after the provider works up the patient. For example... patient presents with chest pain. After workup (labs, xrays, mri's), the provider gives a dx code of chest wall muscle strain and patient gets meds and goes home. If you go on chest pain that would be high on table of risk because chest pain could be a lot of things - some of which are serious - but if you use the final dx of chest wall muscle strain then this is more a low complexity. Thoughts?
I tend to lean towards using what the provider finds
Would love input...

Thanks!
 

mitchellde

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Hello -
We are having a debate in my office about the nature of the presenting problem. We are having conflicting views on this and we are currently auditing ER visits. In relation to the table of risk... do you look at the presenting symptom or do you look at what was found after the provider works up the patient. For example... patient presents with chest pain. After workup (labs, xrays, mri's), the provider gives a dx code of chest wall muscle strain and patient gets meds and goes home. If you go on chest pain that would be high on table of risk because chest pain could be a lot of things - some of which are serious - but if you use the final dx of chest wall muscle strain then this is more a low complexity. Thoughts?
I tend to lean towards using what the provider finds
Would love input...

Thanks!

I feel you need to go with the presenting problem as being the complaint of the patient on presentation. Given that the provider has no idea at the time the exact nature of the issue, it requires more complexity to arrive at the answer. You cannot effectively base the providers decision to perform the type of exam and complexity of information based on what he did not know at the time.
 

CodingKing

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I agree, nature of presenting problem here is what it should be based off. Many things can present as urgent and then turn out not to be. The Provider had to do the work to rule it out so that should count. You don't ignore all that work just because in the end it was nothing serious.
 

bdette810

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coding dx

maybe I am not reading into it enough. I would think that the more specific dx would be the diagnosis found after clinical findings such as labs and xrays etc.
 

mhstrauss

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maybe I am not reading into it enough. I would think that the more specific dx would be the diagnosis found after clinical findings such as labs and xrays etc.

The OP isn't asking about the dx; they are asking about which level of complexity this scenario fits in on the Table of Risk in MDM.
 
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