tci ED Coding & Reimbursement Alert - 2010 Issue 9

Reader Questions: Consider Secondary Diagnoses on Multi-Complaint Patients

Question: A patient presents to the ED complaining of a headache that has gotten progressively worse over the past four days. She complains of blurred vision and vomiting with nausea. Notes indicate that the patient has had four of these types of headaches in the past two weeks. The system review included a detailed neurological examination and a general system exam to address the patient's presenting condition. After assessment and discussion with the patient, the physician diagnoses "migraine w/ aura and Blurred vision NOS" and provides the patient with prescription medication. Notes indicate a levelfour ED E/M service. How...

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