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Which 4 ER diagnoses?

  1. #1
    Default Which 4 ER diagnoses?
    Medical Coding Books
    The ER physician has listed, in no particular order, these diagnoses:

    Heroin overdose, anemia, and pcp pneumonia. And the patient's history tells me that he is HIV+. So I have to give one diagnosis slot to the HIV. To properly code the heroin overdose, I know I'm supposed to use 3 codes--one to indicate poisoning, one for the manifestation of the poisoning, and an E-code for the poisoning. The HPI tells me the patient came in with an alteration of mental status, so I know that is what the manifestation should be. But it really seems as if the pneumonia is too important to omit, although it is not really a manifestation of the poisoning--will the world end if I code that instead of the alteration of mental status?

  2. #2
    Columbia, MO
    The PCP pneumina is a manifestation of the HIV which he may had prior to the heroin overdose so I would go with the poisoning as the reason for the ER encounter.

    Debra A. Mitchell, MSPH, CPC-H

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