ED Coding and Reimbursement Alert

When the heart is weak, report high-level E/M confidently

Chest pain is always an emergency, regardless of the patient's final diagnosis. Solve this case study and see if you know what to report when push comes to shove with a patient's heart.

Physician's documentation

Presenting complaint: Chest pain

History of present illness: 44 yo otherwise healthy male with no prior history of CP presents with intermittent episodes of substernal chest pressure, 5/10 severity, lasting up to 5 minutes throughout the day. Worse with movement or inspiration. No diaphoresis or SOB. Family history of CAD. No pain right now; took aspirin at home. Is a smoker. Past appendectomy.

Review of systems: (as per HPI) Full ROS otherwise (-)

Physical examination:
Alert VS reviewed BP 150/90 HEENT: (-)
Chest Clear  
Cor: RRR No murmur    
Abdomen: No tenderness or masses
Extremities: No swelling, edema, or rashes   
Neuro: No focal abnormalities

ED course of treatment: IV, 02, maintained on monitor. EKG Interpretation: study done for chest pain. NSR rate 84 nonspecific lateral changes, intervals normal. No prior tracings for comparison. Initial myoglobin and troponin (-). Continued to be pain-free throughout stay.

Disposition: Discussed with his PCP. Patient is an appropriate candidate for transfer to observation. Talked with our physician in the observation area and wrote orders for transfer.

ED diagnosis: Acute chest pain - evaluation for possible acute coronary syndrome.  10 pm: Admit to observation for evaluation of chest pain.

Observation note: Patient received from my partner in ED. Discussed case; reviewed studies. Agree with H&P. Will do serial cardiac enzymes and EKGs to evaluate for acute coronary syndrome. Patient on monitor. Repeat myoglobin and troponin; still nondiagnostic. 2nd EKG unchanged. At 0400 hours on the 16th he had recurrent pain. Evaluated him then and did 3rd EKG. Tracing showed a rate of 84 with NSR with ST segment elevation in leads 1, aVL, V5-6, consistent with lateral ischemia. Gave SL NTG and started on drip. Discussed with cardiology; he's going to cath lab. Given Integrilin and Atenolol before leaving observation. Will be admitted to hospital after cath lab.

Discharge summary: Patient to observation, where repeat EKG showed ST elevation consistent with acute MI.

Disposition: Cath lab followed by inpatient admission.

Diagnosis: Acute lateral MI.

Note: The same group runs the emergency department (ED) and the observation unit, and the ED doctor admitted the patient to his primary medical doctor the day after he presented to the ED.



Choose 1 Code for 2 Same-Group Physicians Many payers will consider the services provided by members of the same group and specialty to be of the same provider. When this is the case, you should report only the more comprehensive evaluation and management code. With this patient, that code is from the observation series: 99220 (Initial observation care, per day, for the evaluation and management of [...]