Emergency Medicine CDI – CDI Training

TVH Emergency Medicine

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Tachycardia (Unspecified) Try to avoid R00.0.

Fast heart

Sinus Tachycardia or SVT

Racing

Palpitations

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Alcohol Intoxication vs. Withdrawal A patient is drunk and shaky. Document:

Drunk

Acute Alcohol Intoxication" AND/OR "Alcohol Withdrawal" (if criteria met).

ETOH on board

Drinking

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CO Poisoning Fire victim.

Smoke inhalation

Toxic effect of Carbon Monoxide" (Accidental).

Coughing

Sooty airway

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Laceration Repair To bill the repair correctly, document:

Sutured

Length (cm), Location, AND Complexity (Simple, Intermediate, Complex).

Closed with stitches

Wound repair

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Hyperkalemia K+ is 6.5. You treat with insulin/glucose/calcium.

High K

Hyperkalemia

Electrolytes

Kidney failure

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Animal Bites Dog bite. Document:

Dog bite

"Bite" AND "No puncture/Open Wound" vs. "Laceration" vs. "Puncture."

The animal type (Dog) and encounter (Initial).

All of the above

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Fracture Specificity: Open vs. Closed If you do not specify, the default code is "Closed." If the bone is visible or there is a wound communicating with the break, document:

Bad break

Open Fracture" AND Gustilo-Anderson classification (Type I, II, III).

Compound fracture

Bone exposed

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DKA Diagnosis High sugar, ketones, acidosis.

High sugar

Diabetic Ketoacidosis" (DKA).

Diabetes

Hyperglycemia

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Asthma Exacerbation "Asthma attack" is vague. Document:

Asthma

"Acute Severe," "Moderate," or "Mild" Asthma Exacerbation.

Wheezing

Status Asthmaticus

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GI Bleed Source Hematemesis or Melena?

GI Bleed

Upper GI Bleed" vs. "Lower GI Bleed"

Bloody stool

Bleeding

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Ectopic Pregnancy Confirm location.

Pregnancy issue

"Tubal," "Ovarian," or "Abdominal" Pregnancy.

Ectopic

Bleeding

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Pneumonia Specificity X-ray shows infiltrate.

Pneumonia

Community Acquired," "Aspiration," or "Multilobar" Pneumonia.

Infiltrate

Chest infection

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Chest Pain: Non-Cardiac Causes If you rule out MI, document the likely cause to justify the visit (and avoid "Chest Pain" as the final code).

Non-cardiac chest pain

Gastroesophageal Reflux (GERD)," "Costochondritis," or "Musculoskeletal Pain."

Chest pain NYD

Normal heart

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Anaphylaxis vs. Allergic Reaction Systemic vs Local.

Allergy

Anaphylactic Shock" (Systemic/Hypotension/Respiratory) vs. "Allergic Reaction

Rash

Swollen lip

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Heat Stroke Hyperthermia/confusion.

Overheated

Heat Stroke" vs. "Heat Exhaustion

Dehydration

Sun stroke

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Rule Out" Diagnoses in the ER Unlike inpatient coding, ER coding (outpatient) cannot code "Probable," "Suspected," or "Rule Out" diagnoses. If you are unsure, what must you document?

Rule out MI

The presenting signs/symptoms

Possible Heart Attack

Check up

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Epistaxis Nosebleed requiring packing.

Nosebleed

"Epistaxis" (Anterior vs. Posterior).

Bleeding nose

Trauma

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Critical Care Time To bill for Critical Care (CPT 99291), you must document:

Critical patient

Total time spent (minimum 30 minutes) treating a life-threatening condition, excluding procedure time.

ICU consult

Severe illness

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Conscious Sedation Reducing a fracture.

Sedated

Moderate Sedation

Knocked out

Meds given

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Acute Respiratory Failure A patient is hypoxic (pO2 < 60) or hypercapnic. Documenting "Respiratory Failure" vs. "Respiratory Distress" is critical because:

Failure" is a life-threatening diagnosis (MCC); "Distress" is a symptom.

Distress" pays more.

They are the same

Failure" implies intubation

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Hypertensive Emergency BP 200/110 with headache or blurry vision.

High BP

Hypertensive Emergency" (implies end-organ damage).

Hypertension

Elevated BP

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Abdominal Pain Location "Abdominal Pain" is unspecified (R10.9). Specify:

Stomach ache

Quadrant: "RLQ," "LLQ," "Epigastric," "Periumbilical."

Belly pain

Gut pain

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Cholecystitis Ultrasound findings.

Gallstones

"Acute Cholecystitis" with "Cholelithiasis" (stones).

Biliary colic

GB attack

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Syncope vs. Collapse If a patient fainted, "Syncope" is better than "Collapse" because:

It sounds better

Syncope" (R55) is a specific medical diagnosis; "Collapse" is a vague symptom.

It implies a cardiac cause

It allows admission

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Homelessness (SDOH) Relevant for discharge planning/risk.

No home

Homelessness

Social issue

Vagrant

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Intracranial Injury Positive CT (bleed).

Brain bleed

Specific type: "Subdural," "Epidural," "Subarachnoid" Hemorrhage AND "Traumatic" vs "Spontaneous.

Hemorrhage

Stroke

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Needlestick Injury External cause.

Poked

Accidental puncture" during procedure or handling.

Needle

Sharps

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Burns: TBSA Required for all burn patients.

Burned arm

Total Body Surface Area (TBSA) percentage AND Degree (2nd/3rd).

Bad burn

Fire

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Sepsis vs. SIRS You start the Sepsis protocol. To validate the diagnosis and severity, document:

SIRS positive

Sepsis" AND the specific organ dysfunction.

Infection

Bacteremia

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Atrial Fibrillation with RVR Patient comes in with HR 140 and Afib.

Afib

Atrial Fibrillation with Rapid Ventricular Response (RVR)

Tachycardia

Irregular heart

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Vertigo Differentiate.

Dizzy

Benign Paroxysmal Positional Vertigo (BPPV)" or "Central Vertigo

Spinning

Unsteady

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Abscess I&D You drain an abscess. Document:

Drained

Simple vs. Complex

Popped

I&D

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Foreign Body Child swallowed coin.

Swallowed object

Foreign body in [Esophagus/Stomach/Trachea]

Coin

Choking

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Intubation Medical necessity.

Tube in

Endotracheal Intubation" for "Acute Respiratory Failure" (or Airway Protection).

Vent

Breathing support

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Suicide Attempt Use the correct Z-codes?

Yes

Only psych does this.

Depression

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Concussion Patient hit head, negative CT.

Head injury

Concussion (with or without loss of consciousness).

Minor head trauma

Bump

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Testicular Torsion Emergency.

Groin pain

Torsion of Testis

Swollen testicle

Emergency

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Appendicitis CT confirms.

Appy

Acute Appendicitis

Abdominal pain

Inflamed appendix

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CPR If you perform compressions.

Code

Cardiopulmonary Resuscitation" (Procedure) AND "Cardiac Arrest" (Diagnosis).

Resuscitation

Chest compressions

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Diverticulitis CT findings.

Diverticulosis

"Acute Diverticulitis" (with Abscess or Perforation = "Complicated").

Infection

Colon issue

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Hypothermia Low temp found.

Cold

Hypothermia

Low temp

Exposure

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Rape/Assault Documentation sensitivity.

Rape

Adult/Child sexual abuse, suspected

Assault

Attack

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Overdose: Intent A patient ingests a bottle of pills. "Overdose" is not specific enough. You must document:

Too many pills

Intent: "Accidental," "Intentional Self-Harm" (Suicide attempt), "Assault," or "Undetermined."

Drug use

Poisoning

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Kidney Stone Patient has renal colic.

Stone

Calculus of Kidney" or "Ureter" AND "with Hydronephrosis" (if present).

Back pain

Renal colic

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CVA (Stroke) vs. TIA If symptoms resolve within 24 hours and MRI is negative:

Stroke

Transient Ischemic Attack (TIA)

Mini-stroke

CVA

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