# Help with E/M code



## skelly (Jul 11, 2013)

Can I throw this out to the group.  A young male presents to the Ed with complaint of abdominal pain. The MD documents an detailed history, detailed exam and complete PFSH. In the ROS there are no other symptoms such as n/v, diarrhea, fever.  No tests are administered other than a bedside ultrasound, and lidocaine is given while in ED.  The patient pain is minimized with the lidocaine, and the md prescribes Pepcid 10 mg twice a day for 10 days.  What E/M code should be assigned for this visit?


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## jimbo1231 (Jul 12, 2013)

*Need More Info*

A couple of questions. Did the physician actually document the pertinent negatives in an itemized way as well as the positive. no nausea etc. I'm taking it that the physician did document 4 HPI elemets. Did he/she describe the severity and duration of the pain?
Also did the physician document a review or interpertation of the of the Ultrasound sound.  
This is somewhere between a 99283 and 4 but need more info.
Are you certain no ther labs were done, urinalysis etc?

Jim


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## MarcusM (Jul 12, 2013)

emergency ultrasound is rather a highly focused, limited, goal-directed exam with the expressed purpose of answering a select set of questions: Does the patient have gallstones? Is a pericardial effusion present? Is there an abdominal aortic aneurysm (AAA) or a foreign body? “There are times when the emergency physician who is evaluating the patient can answer a question faster if he can pull an ultrasound machine to the bedside.  Did your MD perform the USound, or did someone else?  Coordination of care, high level of decision making, CPT 99284.


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## skelly (Jul 12, 2013)

Thanks to both of you for responding.  There were no other symptoms other than the abdominal pain.  The results of the bedside ultrasound were not documented. The patient did feel better after the GI cocktail and the provider documents that is is unlikely chole or biliary colic and patient is low risk.  The History, ROS and Exam all meet the requirments of a level 3 or 4 visit, but MDM, I am struggling with. Isn't pepcid 20 mg an OTC drug? Or can I justify that it is a Moderate Risk since lidocaine PO was given during the encounter.  

Sue


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## jimbo1231 (Jul 12, 2013)

*OK*

Sue,

Wish they had a 99283.5 code! But I generally agree with Marcus that with the Ultrasound and as you said lidocaine administered for abdominal pain it does kind of smell like a 4. I think some of the strict adherents to the Marshfield Tool might have a problem with the MDM. As you know, more points if there is some documentation of the US findings. But I think it squeaks in as a 4. But certainly open to other opinions.

Jim


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## Sueedwards (Aug 11, 2013)

This might be late in the game, but was there any follow up with either the ER or a PCP?


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## skelly (Aug 13, 2013)

Hi Susan,

No, no follow up...


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