RE: ED EM Questions

Two Questions - Any opinions would be greatly appreciated.

1. If the ED provider states Chest Pain in the reason for visit /Chief Complaint - Can we use this as Chief Complaint and Location as an HPI element, if he does not restate it ? Or, is this considered double dipping?

2. If the ED provider orders an oral medication while the patient is in the ED but does not "prescribe it and they are not seeing patient back or "managing" the patient once when they leave the ED and this is a 1x admin in the ED, can we count this as Med Management on the Table of Risk?

Thank you
Tina Bradshaw, CPC,COSC



Comments

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    Hi Tina,



    1. If the ED provider states Chest Pain in the reason for visit /Chief
    Complaint - Can we use this as Chief Complaint and Location as an HPI
    element, if he does not restate it ? Or, is this considered double dipping?



    It would not be double dipping but I would urge caution with complaints that
    seem to have location built into them. I have had some audits ( 1 OIG, 3
    carriers and 2 Medicaid payers) where they did not allow counting location
    for complaints like chest pain, headache and abdominal pain. Their position
    was that chest pain was the complaint and they wanted a location descriptor
    like left, right, substernal etc. Same with abdominal pain i.e. RUQ, LUQ,
    etc. But have also had audits where it was not an issue that was even
    mentioned by the auditor. That being said.. If that is the only thing
    preventing the coder from assigning a E&M code that most accurately
    represents the service that was provided I would go ahead and assign the
    higher code and be ready to defend the decision in an audit situation.



    2. If the ED provider orders an oral medication while the patient is in the
    ED but does not "prescribe it and they are not seeing patient back or
    "managing" the patient once when they leave the ED and this is a 1x admin in
    the ED, can we count this as Med Management on the Table of Risk?

    If the providers treatment decision is that the patient needs prescription
    strength medication it can be counted as mod risk, regardless of whether it
    was administered in the ED written as a script to be filled at the pharmacy.




    Hope this helps.



    TT



    Todd Thomas, CPC, CCS-P ERcoder, Inc

    President 941 NW
    164th, Suite 1

    todd@ercoder.com
    Edmond, OK 73013

    (405) 749-2633 www.ERcoder.com



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