Clinical Documentation and Coding in the Emergency Department

Clinical Documentation and Coding in the Emergency Department

The Emergency Department is complex in so many ways; it is like an amalgam, part outpatient encounter, part hospital encounter. So, one might ask themselves how this impacts documentation and coding in the emergency department. It is best to ponder the basics of excellent documentation in answering that question. When we think of any professional medical evaluation, it all starts with presenting symptoms. Some providers may be shocked to learn of the significance of documenting the chief complaint (also known as reason for the visit). Clinically the initial presenting symptoms are extremely important, as they impact triage, immediate treatment, stat orders, possible need for a specialist consultation and more. In terms of documentation and coding the presenting symptoms establish medical necessity. Medical necessity must be established when documenting any professional medical encounter.

What coding to use in the Emergency Department

As it pertains to clinical documentation and the use of ICD-10-CM codes, it is widely known that one should select the most specific and accurate diagnosis code. While this is true, it is not always possible to know the diagnosis. Therefore, in the setting of the Emergency Department it is very important to document and code signs and symptoms. The ICD-10-CM Coding Guidelines contain an entire chapter (chapter 18) which includes, “Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99).”

Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter. If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

In addition to the presenting symptoms, it equally important to document an authentic physical exam. Why use the word “authentic?” We are in the era of electronic health records when one click of a mouse can populate your documentation with a Physical Exam. This is potentially problematic, because providers often fail to go in to make the necessary prepopulated template to document an authentic and accurate Physical Examination for the current encounter.

As stated above, the ED encounter may be the first documentation of what ends up being an inpatient stay. In these cases, the documentation and coding of the Emergency Department findings are helpful in establishing conditions that are present on admission, such as a skin ulcer, to name one such condition. Documenting the exact nature of the skin ulcer including the stage of the ulcer (description of necrosis, color, presence or absence of pus, eschar, etc.) and a picture, when appropriate, may help document the presenting physical exam findings.

Consider the following example:

A 59-year-old male presents to the ED with a rapid heart rate, shortness of breath, and chest discomfort. He is alert and oriented, but in some discomfort. You immediately assess him to be hypertensive, tachycardic, and in an abnormal rhythm (identified as Atrial Fibrillation with a Rapid Ventricular Response).

The patient has no prior history of heart disease or Hypertension; but he has a strong family history of Atrial Fibrillation.

This patient may be documented and coded as having chest pain (R07.9), shortness of breath (R06.02), high BP, and Atrial Fibrillation (I48.91).

Instead of coding this as Hypertension I10 (which is the chronic condition Hypertension), it could be coded as R03.0 Elevated BP reading (not necessarily chronic Hypertension). The symptoms may all be attributable to the A. Fib. But they could be attributable to an underlying Myocardial Infarction, for which he will be admitted to rule out. Regarding the Atrial Fibrillation, this is not a chronic condition for this patient. Therefore, one would want to be careful in selecting the Atrial Fibrillation code. Later he may develop chronic persistent Atrial Fibrillation, which would have an impact on the code selection, as well as the clinical management (anticoagulation and such).

About the Author

Barbara Lennon, MD

Barbara Lennon, MD

Clinical Documentation Specialist