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Q: Where do you get your admitting dx code from when you are coding an inpatient encounter? I am getting different responses from different people. Some say the chief complain on the H&P or the ER report, other say the final assessment dx off of the H&P. For example H&P and ER report say short of breathe but the the assessment/plan part of the H&P says COPD with acute exacerbation.
A: The admitting order should be on the physician's admitting order in accordance with CMS guidelines.
Hospital Inpatient Admission Order and Certification
As a condition of payment for hospital inpatient services under Medicare Part A, section 1814(a) of the Social Security Act requires physician certification of the medical necessity that such services be provided on an inpatient basis. The order to admit as an inpatient ("practitioner order") is a critical element of the physician certification, and is therefore also required for hospital inpatient coverage and payment under Part A. The physician certification, which includes the practitioner order, is considered along with other documentation in the medical record as evidence that hospital inpatient service(s) were reasonable and necessary. The complete requirements for the physician certification are found in 42 CFR Part 424 subpart B and 42 CFR 412.3.
- Arlene F. Baril, MHA, RHIA, CHC
Q: If a child is seen and "clinically" diagnosed with a growth plate fracture and stablized with aCAM walker (noted that x-ray showed no fracture) is a fracture management code able to be applied with this scenario? Can a Provider still bill fracture management when they clinically diagnose it even though x-ray states no fracture? I know growth plate fracture are hard to see on an x-ray. Would appreciate your help!
A: Based on the information provided, there was no procedure done that would qualify for the assignment of a CPT procedure code. The application of a CAM walker is only reported with HCPCS codes such as L4360 (walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment) and/or HCPCS code L4386 (walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment). Any other work done would have to be reflected in the E/M code only.
- Christina Benjamin, MA, RHIA, CCS, CCS-P