As a medical coder, I always wanted to learn all the coding facilities. The best thing I like about medical coding is that, you can learn everything here. The amount of knowledge you gain while coding a medical report is unbelievable. Initially people have difficulty in coding a medical report, but when they know everything about ICD and CPT coding guidelines, they become expert in coding. I always say that having CPC certification from AAPC and having experience in multiple speciality coding, will always boost your career growth. I see coders who are perfect in surgery coding or only knows about diagnostic radiology, but I hardly see any coder who can code more than two or three specialties. So, we will just discuss about Emergency department (ED) physician side coding. I started learning this facility when I cleared my CPC exam. So, I would just share few tips for coding an ED report.
Documentation given in ED Medical report
The first and most important part in ED medical report is the Chief Complaint (CC). Chief Complaint gives the information about the problem, for which patient has come to ED department. We can also call this CC as the Reason for Visit (ROS). Now, this CC helps us to know the exact diagnosis which made patient to visit ED department.
History of Present Illness (HPI)
This is real a very important section in the ED medical report. HPI gives more information about the chief complaint. Also, it gives any other related diagnosis which are present along with CC in the past. Any other diagnosis present previous which is resolved or still present can be given in HPI section. In injury report, HPI plays av very important role in given the context about when and how the injury has happened. In ED chart, we have to report External code of Injury (E-codes) codes as well, which is generally coded from the HPI section.
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Patient Medical and Social History
Patient Medical History (PMH) is very important. PMH is necessary for coding the chronic conditions like diabetes, hypertension, hyperthyroidism, chronic kidney disease etc. such condition stays for life long and hence should be taken care. Suppose, a patient has diabetes and comes with an hemorrhage in ED department, special attention should be given to him because being diabetic his hemorrhage can cause more complications. Chronic conditions should be coded as secondary diagnosis along with primary diagnosis.
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Allergies are also important section in ED coding. There may be patient who are having allergies to penicillin or any other drugs. Hence, we have separate code for allergies which gives more information about patient health.
Review of system (ROS)
This section includes review of all the system like gastrointestinal, cardiovascular, respiratory etc. of the patient. Each section is studied and its results is documented in the report.
This section includes the physical examination of the patient. It includes all the information about the pulse rate, body temperature, BP, respiration etc. these vital signs helps in giving for information about patient health status. Also, physical examination of each section of the body from head to extremity is done to find out any other diagnosis present in the patient body.
Any diagnostic or surgery performed
During the examination, if the physician order to do any diagnostic exam or to perform a surgery it should be reported along with the ED CPT codes(99281-99285). We have to assign all the procedures order and performed while the patient was in ED department.
Final Diagnosis or Impression
This is the actual conclusion of the ED medical report. This will document what has the physician found finally after performing all the above procedures. The physician will document an disorder or disease present or any fracture for any injury report in this section. Hence, coder should always use the primary or principal diagnosis from this section which will define the whole ED report.
Shortcut tips to code ED Medical report
To code a ED report, you should always focus on the primary or principal diagnosis. Primary diagnosis is always important. So, I always look at the final diagnosis or impression to check what has the physician finally found. Now, once you understand what is the main problem, then you can check the CC, HPI, PMH etc. to find related diagnosis. Do remember your admit diagnosis or Reason for visit ICD code should be related to the primary or principal diagnosis.
Sample Coded Emergency Department or ED report
Chief Complaint: Abdominal Pain
Stated Complaint: ABD PAIN
Information Source: Family
Mode Of Arrival: Car
Home Medications:Home Medications
Allergy/AdvReac Type Severity Reaction Status Date / Time
History of Present Illness
Onset: 15 MIN
HPI:MOM STATES THAT CHILD WAS IN HIS ROOM WHEN HE BEGAN “SCREAMING” COMPLAINING OF ABD PAIN, MOM REPORTS PT WAS IN NL STATE OF HEALTH PRIOR TO SYMPTOMS STARTING. MOM STATES THAT CHILD CAME INTO KITCHEN TO GET JUICE, WENT BACK TO HIS ROOM, A FEW MINUTES LATER BEGAN SCREAMING AND ASKING TO GO TO THE DOCTOR. MOM DENIES RECENT ILLNESS, NO COUGH OR CONGESTION, NO FEVER OR CHILLS.
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Pain Location: Reports: Diffuse
Pain Context: Reports: Spontaneous
Pain Severity: Severe
Pain Radiation: Reports: No Radiation
Adult Abdominal History: Denies: Abdominal Surgery, Urolithiasis, Bowel Obstruction, Similar Pain (dx)
Pediatric History: Denies: Abdominal Surgery, UTI, Prematurity, Intussusception, Cystic Fibrosis, NEC
Modifying Factors: improves with: Nothing
Associated Signs & Symptoms: Denies: Nausea, Frequency, Hematuria, Vomiting, Hematemesis, Anorexia, Diarrhea, Melena, Dysuria, Fever, Urgency, Chills
Oral Intake: Normal
Urinary Output: Normal
ED Past Medical History
– History Reviewed
Yes Nurses notes reviewed and agree except as marked
No Past Medical History: Yes Patient has no past medical history
Patient Medical History
Psychological History: Denies: Substance Use Disorder
Social Medical History
Social History: Denies: Substance Use Disorder
Lives With: Family
Lives In: Home
Pets in House: No
EDM Review of Systems
Review of Systems
Constitutional: negative: Chills, Fever
Eyes: negative: Blurred Vision, Double Vision
Ears: negative: Drainage, Pain
Throat: negative: Pain
Nose: negative: Congestion, Discharge
Respiratory: negative: Cough, Shortness of Breath, Wheezing
Cardiovascular: negative: Chest Pain, Palpitations
Gastrointestinal: Pain. negative: Diarrhea, Nausea, Vomiting
Genitourinary: negative: Frequency
Neurological: negative: Seizure
Musculoskeletal: No Symptoms Reported
Integumentary: No Symptoms Reported
Oriented to: Person (ALERT AND ORIENTED FOR AGE, COOPERATIVE WITH EXAM, NO DISTRESS)
Last recorded Vital Signs:
Last Vital Signs
Temp 99.6 F 01/04/10 19:42
Pulse 141 H 01/04/10 19:42
Resp 24 01/04/10 19:42
Pulse Ox 99 01/04/10 19:42
Pulse Oxygen Saturation 99
O2 Device Room Air
Oxygen Flow Rate
Fraction of Inspired Oxygen (FIO2)
Head: Normal ( normocephalic)
Eye Exam: Normal (PERRL, EOMI, Sclera white)
Oropharynx: Normal (Pharynx:Moist without exudate,Gums-no swelling)
Tympanic Membrane: Normal
ENT EAC: Normal
Nose: No Symptoms Reported (septum midline)
Neck: Normal (FROM, trachea at midline)
Respiratory: Normal – CTA (BBS clear to auscultation without adventitious sounds)
Cardiovascular: Normal (RRR without murmur, gallop or rub)
Auscultation: Normal (NABS)
Tenderness: Diffuse, Mild. negative: Guarding, Rebound, Rigidity
Murphy’s Sign: Negative
Back: Normal (Non-Tender)
Extremities: Normal (Normal tone, Pulses 2+ No cyanosis or edema, FROM)
Skin: Normal, Warm, Dry
Lymphatics: Normal (no adenopathy)
Mood Description: Normal
– Differential Diagnosis
Bowel Obstruction, Constipation, IBS
Re-evaluation: (SMILING, ACTIVE, PLAYFUL, ABD EXAM REMAINS BENIGN, NO DISTRESS)
Image interpreted by: Radiologist
DG ABDOMEN ACUTE W/ 1V CHEST
No evidence of dilated bowel loops. A moderate to large amount of
stool seen throughout the majority the colon. No radiopaque calculi
identified. No evidence of abnormal mass effect.
No acute findings.
Moderate to large stool burden noted.
Abdominal pain, Constipation
Final dx :K59.00, R10.9
CPT: 74022, 99283