tci ED Coding & Reimbursement Alert - 2017 Issue 1

You Be the Coder: How Do You Code for a Patient Presentation When It Appears Nothing is Wrong?

Question: Although this chart is well documented, it appears there is nothing wrong with the patient and no treatment was given other than diagnostic testing. Can we still report an ED E/M code consistent with the documentation without a supporting diagnosis? Kansas Subscriber CHIEF COMPLAINT/REASON FOR VISIT: Syncope/Near syncope HISTORY OF PRESENT ILLNESS: A seven-year-old patient presents with her parents explaining that she nearly passed out this morning. Patient got up about 6 AM to get ready for school. She had breakfast and got dressed. Around 7 AM she was standing in the kitchen while her mother did her...

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