# Hematemesis



## jifnif (Oct 16, 2009)

I know I shouldn't be questioning a doc on if a situation is critical care or not b/c I am not a doc....but I am having a hard time wrapping myself around what exactly is critical care.  I have read the cpt description 1000x plus.  I get if there is failure and what not but can if a doc is called on a pt that has no other symptoms other than hematemesis, is this critical care.  Actually the pt was stabilized prior to the doc arriving.  Please help me understand this sensitive code better.  Does anyone have more specific guidelines that they follow for critical care other than cpt?


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## jifnif (Oct 16, 2009)

*Another Critical Care Question*

I have a note that I would like to post that is critical care...again, please help me clarify that this is a critical care visit.  thank you. 

Chief Complaint/HPI
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Patient is a 65 yr old M presents to MD office this am with c/o feeling dizzy. While at home he reached to turn the stove on felt dizzy and felll down with no true LOC and got him concerned and went to MD office. In MD office BP low so sent to ER. Initially on admit Bp was 70 systolic improved with fluuid challenge. feels less dizzy now. No chest pain, SOB, palpitation sweating through this episode. drinks regularly heavy and r/o withdrawal. Last drink 2 days ago and today had 2 loose BM watery to semi formed. No problems urinating and did urinate prior to going to MD office.  No fevers,cough,phelgm. Chronic erythrema of umbilicus treated with out[pt antibiotics by MD in july

Past Medical History
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Alcoholic active and a member of AAA
Abdominal aorta anuerysm
H/o anginal s/s not recently with ABn stress test
HTN history
CKD baseline creatinine 1.7
h/o alcoholic pancreatitis
GERD
active tob user
Active tob user

History

Home Medication
-

Home Reported Medications
Active
Allopurinol 300 Mg Tablet (Allopurinol) 300 Mg PO DAILY 
Lotensin 10 Mg Tablet (Benazepril HCl) 10 Mg PO DAILY 
Elavil 25 Mg Tablet (Amitriptyline HCl) 25 Mg PO DAILY 
Ambien 10 Mg Tablet (Zolpidem Tartrate) 10 Mg PO HS PRN
Aldactone 50 Mg Tablet (Spironolactone) 50 Mg PO BID 
Lasix 40 Mg Tablet (Furosemide) 1 Tab PO DAILY 
Martinic (Vitamin B12-Intrinsic Factor) 1 Cap PO DAILY 
Prilosec 20 Mg Capsule (Omeprazole) 20 Mg PO DAILY 
Potassium-99 (Potassium) 99 Mg PO DAILY 
Folic Acid 1 Mg PO DAILY 
Reported
Cephalexin 500 Mg Capsule (Cephalexin Monohydrate) 500 Mg PO Q8H 
Ecotrin 325 Mg Tablet (Aspirin) 325 Mg PO DAILY 


Allergies
- 
Coded Allergies: 
No Known Allergies (Verified , 7/2/08)

Social History
-
active alcohol and an alcoholic at r/o withdrawal
active tob user 11/2 PPD
denies drug use

Family History
-
non contributory

Review of Systems
-
refer to hpi

Physical Examination
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vitals noted
S1,S2 + RRR
B/l AE decrterased but no adventitious sounds
Soft, NT BS + with erythrema umbilicus chronic does not seem like source of infection
AAO X3
no edema

Clinical Data
Vital Signs Temperature: 96.6, Heart Rate: 89, Respiratory Rate: 20, BP: 85/46, Pulse Oximetry: 99
-
All data reviewed in the EMR. 

Impression/Plan

Impression
-
Hypotension of unclear etiolgy r/o sepsis r/o MI
ARF
Alcoholic at r/o withdrawal mild s/s now
Hepatitis ? acute vs chronic
H/o Abn stress test
H/o AAA
h/o HTN

Plan
-
ivf, pan cultures and antibiotics
renal US and foley's with strict I/o
CE X3, echo and consult cards
alcohol withdrawal protocol and consult BHU
critical care time spent 45 min


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## FTessaBartels (Oct 16, 2009)

*I don't think so*

First I'm not sure if this is an admission note or an ER visit.
I am also NOT a doctor or a nurse, so maybe I'm missing something. 

Well, the doctor lists ARF in impression ... normally I'd say acute renal failure would *probably* get a patient classified as critically ill.  But I don't see any evidence of exam of kidneys or renal system to get to this diagnosis. (I know he orders a renal US.)

Acute alcohol withdrawal *might* also result in a patient being critically ill ... but this patient is alert and oriented x 3, seems to have pretty good vitals (albeit low BP). Not sure how he was getting around, but it sounds like he took himself to the PCP and probably took himself to the ER (or did he arrive by ambulance?).

In total, the patient just doesn't "sound" critically ill and in great distress. 

I would not code it as critical care.  If this is the ER physician, I'd stick to the ER codes. (Of course then he's got to do a better job of getting his history elements in order to qualify for the higher level of codes.)

What do others think?

F Tessa Bartels, CPC, CEMC


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## LLovett (Oct 19, 2009)

I agree, I don't see critical care here either.

I have a problem when they have all the elements of E/M, critical care is just that, critical. They aren't capturing all this info, they are making decisions to keep the patient alive and functioning. This patient may be critically ill, I'm not clinical either, but it doesn't appear he is in any immediate danger based on this note.

Hopefully one of the nurse auditors will chime in as well.

Laura, CPC, CEMC


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