Wiki To Query or Not to Query


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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.
I'd just go with the e928.9.

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

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?
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.
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.