tci ED Coding & Reimbursement Alert - 2003 Issue 6

Reader Question : Use Documentation From Entire Chart

Question: A patient presents to the ED because a glow stick broke and splashed her in the oculus dexter (OD), the right eye. The ED physician irrigates the eye and discharges the patient. In the eye section of the documentation, the physician notes a "slight conjunctivitis." The discharge diagnosis, however, is "accident to the oculus dexter by chemical splash." Should I report conjunctivitis based on what's written in the eyes section even though it's not written as a discharge diagnosis? New Mexico SubscriberAnswer: You should report the chemical conjunctivitis from the irritants within the glow stick, 372...

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