Coders when coding ER encounters you are reviewing all the information before entering your codes, right! In doing so, your encounter should look like so….(Scenario in my head)
“16 year old male who presents with a complaint of left elbow injury/pain after falling PTA(prior to arrival). He has some swelling and unable to bend at the elbow joint. He denies………
A/P: Fall (NO! NO! NO! PHYSICIANS), sprain of left elbow…………NOW CODE”
Admit Dx: Left Elbow Injury S59.902A
Reason Dx 1: Left elbow Injury S59.902A
Reason Dx 2
Reason Dx 3
Primary Dx: Sprain of Left Elbow S53.402A
Dx: Fall W19.XXXA
Please educate your physicians and let them know they are not TREATING a fall. Ask yourself……How can they do that? All accidents, falls happened already so they weren’t there. The physician must TREAT the result of the fall i.e left elbow injury, burns, lacerations, gunshot wounds etc. It is imperative as a coder, we seek these trends and make sure we are letting our supervisors, managers, coding educators etc know this so that proper education is given to the physician.
CODERS TIP: For some coders I know that External Cause of Injury(NEVER PRIMARY DIAGNOSIS) coding is rather difficult. Please just keep it simple when coding. We must remember the end of our ABC’s and the sequencing of codes all in one. Just think…..
Injury: Usually S and T codes
How?-V and W Codes- How did the injury happen…..falls, accidents, burns, injuries…….Look in the ECI section in ICD-10Cm
What?-X or Y codes- What activities they were indulging in…..athletics, riding, exercises….Look under activities in the ECI section in ICD-10Cm
Where?-Y codes-Where were they….home, school, highway, jail……..Look under place of occurrence in the ECI section in ICD-10CM (if you know the work status you can also code it as well)
Z codes– This is usually tetanus shots(common), statuses, histories…..according to documentation.
Now you’ve conquered the end of your ABC’s and sequencing in coding!
Happy ER Coding!
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