Key Items for Diagnosis and MDM from Dr. Bohrn

by Bob Stuntz in


The medical coding world is undergoing a major transition, with the move to ICD-10 codes for diagnoses.  Our coding company, MedData, forwarded a document with some early recommendations for our ED providers.  See the items below and plan to emphasize or start incorporating these in your notes - this is all critical for both our coding, and for hospital coding for patients who are under Obs or Admission status.  

KEY ITEMS TO INCLUDE IN DOCUMENTATION OF DIAGNOSIS/MEDICAL DECISION-MAKING:

- Type of Encounter (initial or subsequent) - usually "initial" for us in the ED, but could be a subsequent visit

- Applied Specificity: Example - Did the patient lose consciousness with their condition/injury?

- Acute vs. Chronic Conditions (very important for indwelling Foley catheters, bedsores, infections/sepsis and other areas where insurers will not pay for care if deemed to be due to ED/hospital care versus an already present condition)

- Episode of Care (e.g., what trimester for pregnant patients)

- Relief or Non-Relief of Symptoms (e.g., Was this "Intractable" pain?)

- External Cause - (e.g., What caused the injury?) - this is the E-code item we've heard about before (MVC, fall, GSW, tractor crash, etc.) - remember that these cannot be listed as the primary diagnosis without another Symptom/Injury as the primary diagnosis

- Activity - (e.g., What was the patient doing when the injury occurred?) - similar to External Cause above

- Location (e.g., Where was the patient when the injury occurred?) - again, similar to above.  eCARE has a line asking this for most injury templates.

- Laterality (Where is the injury? Left, right, or bilateral).  This appears to be a big item, along with anatomic specificity - see below

- Anatomic Specificity - use bone/location/displacment, etc. for fractures/orthopaedic injuries. E.g., "Acute closed left proximal femur intertrochanteric  fracture with posterolateral displacement" instead of "left hip fracture".  Apparently using non-specific joint descriptions (e.g., hip, wrist, etc.) will not fly with the ICD-10 codes.

 

Dr. Bohrn: Program Director, Wellspan York Hospital EMRP

Dr. Bohrn: Program Director, Wellspan York Hospital EMRP