General Surgery Coding Alert - 2017 Issue 2
You Be the Coder: Not So Fast in Reporting that FAST Exam
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Article Overview
This article is a coding education discussion centered on an emergency department trauma encounter after a motor vehicle collision. It focuses on how the documented exam, imaging, and physician interpretation relate to professional and diagnostic coding, including trauma-related evaluation, limited ultrasound reporting, and injury diagnosis coding. The piece is intended for coders and auditors who review ED documentation, procedure reporting, and trauma-related claims.
Why This Topic Matters
Trauma encounters often include multiple studies and a complex documentation trail. This article helps readers understand how to review the record for appropriate reporting across evaluation and management, imaging, and diagnosis coding in an emergency department setting.
Article Sections
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Case presentation
Introduces the emergency department trauma scenario, including the presenting complaint, injury context, and initial clinical findings.
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Procedures – Physician
Describes the physician-documented bedside trauma ultrasound study and the anatomical areas referenced in the exam note.
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Orders
Lists the categories of tests, imaging, and medications ordered during the encounter.
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Progress Notes
Summarizes the patient’s clinical course, imaging results, and admission planning.
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Diagnosis
Identifies the injury diagnoses documented for the encounter.
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Answer
Explains the coding discussion for the trauma ultrasound study, emergency department visit level, and injury diagnosis reporting.
What You Will Learn
- How a trauma-related emergency department record is reviewed for coding relevance
- How procedure documentation is discussed in relation to bedside ultrasound reporting
- How the encounter’s imaging, labs, and physician involvement are used in coding analysis
- How injury diagnoses in a motor vehicle collision case are presented for coding review
Who Should Read This
- Medical coders
- Coding auditors
- Emergency department coding professionals
- Trauma documentation reviewers
Codes Discussed
Modifiers Discussed
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