tci ED Coding & Reimbursement Alert - 2018 Issue 5

Reader Question: Does This Scenario Require More Information?

Question: A parent brought a newborn patient to the ED with nasal discharge, nasal swelling, and fever. The physician documented a concern for sinus infection. Do I have to ask the physician for more information before I can code this scenario? Supercoder.com Subscriber Answer: Despite the lack of a definitive diagnosis explaining the newborn's symptoms, this diagnosis can be coded as is, without further elaboration by the provider. If, for example, there were a test that the provider could perform to definitively diagnose a sinus infection, then you could send the report back in case the provider performs...

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