tci ED Coding & Reimbursement Alert - 2002 Issue 4

Reader Question: Coding Symptoms or Rule-Out Diagnosis

Question: Our ED physician recently saw a pediatric patient with a very high fever and suspected that the young girl had sepsis. Should we report the diagnosis code for sepsis or for the signs and symptoms she exhibited?New York Subscriber Answer: Correct diagnosis coding in this instance depends on the documentation in the patient record. If the ED physician stated that the diagnosis was sepsis, report the relevant code (e.g., 038.8, Septicemia; other specified septicemias). However, if the physician's notes stated he or she was attempting to "rule out" sepsis, the signs and symptoms should be...

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