To Query or Not to Query

Jacoder

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Part of my job at my hospital is to code the outpatient x-rays. I see a lot with the diagnosis "Truama" which I in turn code as an injury, but I never get an explanation of what the injury is (you know, those E codes). I am torn between whether I should or shouldn't query my physicians about this. I recently sent a query stating that I needed more specification of the trauma such as a fall, MVA, crushing injury, ect. and the provider faxed the query back to me with the diagnosis of "Trauma/Pain."

I think this information is needed, and according to AHIMA, I can query when:

*Clinical evidence for a higher degree of specificity or severity
*A cause-and-effect relationship between two conditions or organism

But then again, maybe I'm reading too much into that. Basically, I know how busy our providers are and I don't want to query them about things that are not required of them.

Are E codes required? Thanks in advance.
 

cosita

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I'd just go with the e928.9.

At my facility, we only query on the inpatient side.
 

Jacoder

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Thanks

Cosita, thanks for the response.

Dadhich.girish, I'm not comfortable coding "observation" since we aren't exactly observing them at our outpatient facility, we're only don't the x-ray.

Any other input?
 

kevbshields

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Observation codes would not be appropriate if symptoms or signs are provided. Trauma/pain are signs and symptoms.

Work on creating a policy that defines how you and the other coders are going to interpret the word "trauma". ICD-9 is very clear. For trauma, "see also, Injury by site." You'd be very safe in doing that.

E-codes are really optional. Sometimes you have the information, sometime you do not. I would be hesitant to code a vague E-code for the injury. It is probably more prudent to leave the E-code off altogether if you lack the specificity in documentation to assign one.
 

tristate

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I've been going through something similar. I do radiology billing and the docs think that I should code injury for things like "fall" or "hand caught in door". According to Coding Clinic first quarter 2006 - you shouldn't assume injury even if it says "trauma" Confusing, huh? Especially since ICD-9 book leads you to injury when you look up trauma.
 
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