secondary conditions in the ED record
Hi, are we able to capture secondary conditions from ED records that are not addressed/mentioned in H&P, subsequent inpatient MD documention (e.g. type of CHF, pt is continued on lasix in the inpt setting; hemiparesis; etc) for inpatient coding/billing?
Comments
I believe that many coders will not code those conditions noted by the ED unless they are "brought forward" (so to speak) into the current record/admission, and addressed/evaluated in some way. I often craft queries to the attending to ask them if the condition is present, still relevant, ruled in/out, etc., something along those lines - especially if I see the patient is being treated as you say with Lasix, Coreg, or if the P.T./nursing is noting hemiparesis. We all know many conditions aren't going to just disappear in between the ED and the patient being admitted, but it's a good idea to get your docs in the habit of including all the patient's pertinent secondary diagnoses for accurate coding.
Hope that helps?
Becky Mann, RN, CDS
Sutter Solano Medical Center
Vallejo, CA