tci ED Coding & Reimbursement Alert - 2014 Issue 1

Reader Question: No Diagnosis Listed? Here's What to Report

Question: I have an ER chart where my doctor listed as the final diagnosis well baby exam V20.2. I know payers don’t like that code and won’t pay. In the ED chart, it says benign exam, in HPI, it says that according to the parents, the patient had decreased urine output, patient crying with urine, no fever. He did labs and also gave IV fluids; the coder coded 788.5 as the final diagnosis, I sent it back to her and told her we could not change the doctor’s diagnosis. What should I have done...

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