The Invaluable Differential Diagnosis

The Complex Problem and Its Simple Solution

Every year, tens of millions of dollars are left unrealized by Emergency Medicine physicians and mid-level providers as a result of inadequate charting.

In regards to reimbursement, shortfalls in the information provided by clinicians results in shortfalls in billing by our coders.

In Emergency Medicine, we commonly overlook or minimize the role our documentation has in detailing the service we provide.

This problem can be overcome by clinicians through the realization that documentation is a skill and can be improved upon across many levels.

  1.  Be complete in your charting in regards to the service you provide.
  2.  Detail the appropriate risk and complexity within each and every case.

A new era has arrived, and value-based care has taken center stage.

Provide your coders and insurers with the information they need to be complete.

The appropriate reimbursement will follow.  On many levels, it is that simple.

Here’s How To Optimize Your Reimbursement

In regards to detailing the appropriate risk and complexity, the importance of including a differential diagnosis in every documented patient encounter cannot be over-stated.

Differential diagnoses provide the foundation of your “medical decision making”.

These help to identify the level of risk involved in a given case.

Establishing the appropriate risk allows your coders and payers to recognize the level of service provided.

This is definitely one area where documentation can help make the difference between a level 3 and 4 or 5 RVU designation for a given encounter.

You can be concise and effective.

No cumbersome annotations are needed – just include a differential diagnosis.

Consider the following examples:

# 1  –  Chief complaint:  “48 y/o with Chest pain” …

“Differential diagnosis  –  ischemia,  MI,  pneumonia,  pneumothorax,  PE,  musculoskeletal,  GERD,  other”

Relatively straightforward – agreed.


# 2  –  Chief complaint:  “2 y/o with Cough” …

“Differential diagnosis  –  croup,  bronchitis,  pneumonia,  RSV,  asthma,  other”

A 2 year old presents with accessory muscle usage and a cough.  A chest X-ray is ordered.

Regardless of the chest X-ray findings, why wouldn’t you include pneumonia and pneumothorax in your documented differential diagnosis?

If you were expecting the chest X-ray to be “normal”, then why did you order it in the first place?


# 3  –  Chief complaint:  “8 y/o with Ankle injury who fell off her bike. Her parents state she also hit her head” …

“Differential diagnosis  –  ankle sprain,  fracture,  dislocation,  head injury,  concussion,  other”

Assuming the patient looked clinically “good” to you via the history you took and your physical exam, why wouldn’t “head injury” still be included in your documented differential diagnosis?

The patient hit her head, and the concern of this was brought to you by the patient’s parents.

In evaluating the patient, you go through the continuum:

mechanism … headache … lightheadedness … nausea … vomiting … LOC … confusion

Your clinical skills are utilized here.  Realize the true level of care you have provided.

Convey this to the coders by listing the appropriate differential diagnosis.


# 4  –  Chief complaint:  “53 y/o with Wound check”

“Differential diagnosis  –  wound check,  cellulitis,  abscess,  MRSA,  other”

If all wounds heal well, there would be no need for medical evaluations.

Have you ever encountered a patient registered as a “wound check” who ended up having a diagnosis of cellulitis, abscess, MRSA, or even necrotizing fasciitis?

If you practice emergency medicine long enough, you will!

Be sure to list a differential diagnosis with all “wound checks”.


# 5  –  Chief complaint:  “84 y/o with Hypotension from nursing home”

“Differential diagnosis  –  dehydration,  myocardial infarction,  sepsis,  pneumonia,  UTI,  GI bleed,  electrolyte imbalance,  renal insufficiency,  other”

This case will likely qualify for critical care.

Be sure to convey its complexity through your charting, including the differential diagnosis.

With your documentation, don’t dismiss what’s “Routine”:

Keep in mind: “Routine” does not necessarily equate to “simple” or “straight-forward”.

Many perceived “level 3” cases which clinicians view as “routine” are in fact level 4 and 5 cases in regards to their potential CPT designations (CPT 99283  vs.  99284 / 99285).

We should realize the complexity of the cases we manage, and convey this in our documentation.

One way to accomplish this is through charting a differential diagnosis with every case  –  let your coders know what you are thinking.

Not comfortable with listing a differential diagnosis?

The alternative is to “document your cognition”.

For example,

Chief complaint:  “56 y/o with Chest pain” …

“The patient is a 56 year old male with a history of diabetes and HTN with a complaint of chest pain.  I feel this patient is at significant risk for having unstable angina / acute coronary syndrome.

Other considerations include pneumonia and pneumothorax, however the patient has no cough, shortness of breath, or fever.  The patient has no leg swelling or pain, no history of recent travel, and no history of DVT or PE, therefore I do not feel the patient’s presentation is consistent with pulmonary embolism.”

Now, compare this to …

“Differential diagnosis  –  ischemia,  MI,  pneumonia,  pneumothorax,  GERD,  pulmonary embolism,  other”

Both reflect cognition and highlight the risk within the patient’s encounter.

Ask yourself – Which saves time?  Which would you prefer documenting during a busy shift?

Listing your Differential Diagnosis is a Great Start.

Yes, listing a differential diagnosis with every patient encounter is a great start towards consistently producing high-quality, optimal documentation.

Take a step-wise, systematic approach to charting with every case.

The end result is your coders will have the information they need to be complete.

You need only to detail the service provided and convey the appropriate risk and complexity through your proper charting.

Optimal reimbursement for the care which you have provided will follow.

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