tci ED Coding & Reimbursement Alert - 2000 Issue 2

Case Study: Appropriately Coding Unsuccessful Treatment

To correctly code for a patient who presents in the emergency department (ED), including attempted treatments that were unsuccessful, coders must determine what, if any, procedures can be reported in addition to the overall service. We provided the following documentation example to two expert coders and asked their opinions of the correct way to code the visit. In this case Dr. B is the emergency room physician (providing the documentation) and Dr. K is the surgeon. Documentation of Examination and Treatment History: This is a 79-year-old white male with the chief complaint of abdomen pain. Patient has been having...

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