tci ED Coding & Reimbursement Alert - 2012 Issue 9

You Be the Coder: Should I use an established patient code for a known patient?

Question: How should we report the following? The patient complains of a headache. The History of Present Illness shows she is an otherwise healthy 34-year-old female with a history of chronic migraines that our ED has treated before. She has had her typical throbbing frontal headache for 24 hours and isn't responding to her normal medications. She requests a shot. She says she doesn't have fever, a stiff neck or focal neurologic symptoms. She does have nausea with vomiting. She also continues to smoke and drinks at least four caffeinated beverages a day. The physical exam shows that she's...

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