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Emergency Department Coding & Reimbursement Alert

You Be the Coder:

How Do You Code for a Patient Presentation When It Appears Nothing is Wrong?

Question: Although this chart is well documented, it appears there is nothing wrong with the patient and no treatment was given other than diagnostic testing. Can we still report an ED E/M code consistent with the documentation without a supporting diagnosis? Kansas Subscriber CHIEF COMPLAINT/REASON FOR VISIT: Syncope/Near syncope HISTORY OF PRESENT ILLNESS: A seven-year-old patient presents with her parents explaining [...]