I code for BH and I receive BH assessments (completed by LSCSW) in the ER. I am having issues with the diagnosis coding.

On one hand there are the diagnoses, signs, and symptoms the patient (or outside source) reports. On another hand the LSCSW reports different (or the same) diagnoses in the EMR – note I also receive paper tickets for these encounters. Then on my paper tickets the LSCSW writes down a different (or the same) diagnoses than what is in the EMR.

These assessments are detailed and can have conflicting information from the many persons involved in the patients care. What should I do? I don’t want to code these incorrectly. The conflicting information makes my head spin. What all should I be taking into account? Who should I be taking into account when assigning the diagnoses? :confused:

Any help is appreciated!