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Thread: Question RE admit dx

  1. #1

    Default Question RE admit dx

    AAPC: Back to School
    I am a newly certified coder and I am in the process of taking an online exam for a remote coding job. Please note - I am not looking for answers to the questions! Rather - I need clarification on 2 issues and hope someone out there can help.

    The exam involves coding several ER visits. None of the patients are admitted; only discharged, transferred or expired. The exam instructions are as follows: "Coding Scenarios—Assign all diagnosis codes including V-codes and E-codes. Assign all procedure codes using both ICD-9 and CPT codes. (Code all procedures including EKGs, ABGs, Injections, Infusions, etc.) Assign Facility E/M levels. Add modifiers when appropriate." It doesn't specify coding for physician or facility. The exam asks for Admit Dx, Primary Dx and any Secondary Dx on each scenario.

    1. I thought the Admit Dx was only necessary for inpatient coding. Should use the chief complaint to code the admit dx?

    2. Can anyone explain 'facility E/M levels?' I've coded E/M for physician billing, but not for the facility. Again - any advice on this?

    I did great on my CPC exam, but I am having a LOT of doubts today. Any help would be appreciated.


  2. #2


    OK, a little feedback for you.

    When coding diagnoses for any OP encounter, most data entry systems want the "admitting dx" and the "primary dx". Most of the time they are the same (so you would code it twice), but not always. For example in an ER, if a pt presents with a cough (cheif complaint), but the final dx is pneumonia. Cough would be the admitting dx and pneumonia the final dx.

    As for the facility E/M, did they tell you which guidelines to use? There are many different ways to determine the facility E/M. It is based on the facility resources used to treat the patient. There is a set developed by ACEP and several others. Facilities can also make their own. So they need to tell you which guidelines to use.

    Hope this is helpful.

  3. #3



    The exam instructions didn't specify what guidelines to use for the facility coding. I found the ACEP guidelines online. I will double check with the examiner on that. Your explanation of the admit dx confirmed my own houghts. This is so humbling. Thank you so much for your help!!


  4. #4


    And I'm so flustered, I spelled your name wrong. Sorry - Cathy.

  5. #5


    The ACEP guidelines are about the only ones you will find online. Many others sets of facility guidelines I have seen are "home grown" by the facility I was coding for. CMS allow you to make up your own facility guidelines.

    Also when doing the test see if they want you to code the ICD-9 codes for the procedures (Vol 3) codes in addition to the CPT codes.

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