tci ED Coding & Reimbursement Alert - 2009 Issue 3

Reader Questions: Use Symptom ICD-9s to Explain 'Emergency'

Question: A mother brings her 6-year-old son into the ED on a Saturday afternoon; she reports that the child has been screaming for almost nine hours due to pain in his right ear. During a level-three E/M, the physician diagnoses otitis media. Can I just code for the final diagnosis, or should I include ear pain as well? Massachusetts Subscriber Answer: You might want to include an ear pain diagnosis, just to be safe. Without the ear pain diagnosis, some insurers could question whether the child required emergency care in this situation. On the claim, report the following: -...

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