Health Information Management

Q&A: Emergency room documentation and radiology reports

CDI Strategies, December 10, 2015

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Q: Can you code strictly from emergency room (ER) documentation? Can you code from test results and imaging (radiologist reports)?

A: Coders can assign diagnosis codes based on documentation of any licensed independent provider that provides direct care to the patient. This includes physicians, nurse practitioners, and physician assistants who provide care to the patient during this encounter. Thus, the documentation of ER physicians or other providers (nurse practitioners and physician assistants) can be used to assign a code.
 
Two elements of caution, however. First, this documentation must not conflict with the attending physician. If the documentation conflicts, then query for clarification. Second, if the ER physician documents a diagnosis, but you see no evidence of treatment or monitoring continued through the inpatient stay, query for the significance of the diagnosis.
 
As for the second piece of your question, diagnoses codes cannot be assigned based on test results or imaging. The documentation of radiologists and pathologists cannot be used to assign diagnoses codes, as such physicians do not provide direct patient care. We would need to query the attending provider to assign the appropriate diagnosis code.
 
Further guidance exists from the AHA Coding Clinic for ICD-10-CM/PCS regarding the use of such reports to further specify the location of a fracture or cerebrovascular accident (CVA) from imaging. But we first must have the diagnosis as documented by the attending physician or provider responsible for the direct care of the patient.
 
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.



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