Emergency Room/Department Coding Guidelines

Emergency Room/Department coding is one of the most simple type of coding. It involves diagnostic coding and simple procedural coding(CPT/HCPCS).

Assign ICD-9-CM diagnosis codes for the Admitting Dx and all Other Dx. Other diagnoses would include all chronic conditions that the patient may have and other documented diagnoses that would justify the tests performed in the ER. These codes are picked up for medical necessity purposes. The first listed diagnosis should be the primary diagnosis for which the patient came to the ER for. ICD-9-CM and CPT procedure codes need to be assigned for procedures. E-codes need to be assigned as per ICD-9-CM Official Guidelines for Coding and Reporting (for injuries, poisonings and adverse effect of drugs).

Some common Emergency Room/Department (ER/ED) procedures are:

Any scopes (ie: EGD, Laryngoscopy)
IV’s, IVP’s and IVPB
SQ & IM Injections
Drainage of Abscess
Shots/Vaccines (administration and vaccine product)
Foreign Body Removal
Nasal Packings/Cautery
Foley Caths
Spinal taps
ABG (36600)
Nebulizer Treatments
X-rays, CT, Ultrasounds, MRI
Pulse Ox
Venous Puncture/Lab Draw (36415)

These are general Emergency Room/Department (ER/ED) guidelines. However guidelines vary slightly from facility to facility. Also some of the procedures will be chargemastered so no need to code them.

Tags: Emergency department coding, emergency medicine coding, urgent care coding, career emergency room coding, emergency room coding guidelines

1 comment:

jeeva said...

Very Nice

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