ED Coding and Reimbursement Alert

EMS Prehospital Care Report Form: Call Received911/Dispatch; Aid Before ArrivalFirst Aid, No Prearrival Instructions; Code to Scene3; Incident SiteOther/Laundry; Nature of CallCardiac Arrest; TransportPatient was Transported, Yes; Past Medical HistoryUnknown; Total Scene TimeNo indication; Personal Protective EquipmentGloves; Glasgow Coma Score-3, Invasive ProceduresEndotracheal Intubation (ET) and IV; Entered into Trauma SystemNo.

Emergency Room Outpatient Record FormMedical Screening ExamNursing Notes: Time19:08: Patient in code 99 (arrived) via EMS. CPR in progress. Patient has an established IV in LAC, is intubated and being bagged. Patient was found unconscious, unresponsive at a local mini-market. EMS reports patient may have been down for more than 20 minutes. EMS has given ACLS medications epinephrine and atropine. Patient in systole for a time, then an agonal rhythm. Patient placed on monitor. Code team is present. 19:20: Patient continues in agonal rhythm without a pulse. CPR has continued per ACLS protocols. (See flow sheet.) Patient has dilated, fixed pupils, extremities cold and slow/little cap refill. BP is unpalpable. No spontaneous respiration. Patient has PEA. CPR continued. Arterial blood drawn by RT. NG placed. Patient continues without spontaneous respirations or circulation. No palpable pulse or BP. Patients color is mottled and beginning to show discoloration at dependent areas. 19:28 B Time of death called by MD. 19:35: Police department notified via phone of patients death, requested to contact family. 19:45: Patient extubated and IV removed. 20:40: Patients body is released to Belair Funeral Home. Family notified via phone of patients death by house supervisor. Belongings sent with patient to funeral home.

Emergency Room Outpatient RecordPhysician Dictation: Subjective: This is a 54-year-old male who was found tonight. Apparently, he was sitting in the laundromat in a chair. People noticed him to be sitting in the chair without moving for at least 20 minutes prior to somebody going over and checking on him. He was found to be unresponsive. 911 was called and the ambulance responded. They found him to be, in fact, nonresponsive with an agonal rhythm. He was intubated in the field and an IV was started. He received 4 mg of epinephrine and 3 mg of atropine in the field and arrived here in the emergency room at 19:08 hours. He was placed on a monitor which showed agonal rhythm. He received an additional milligram of epinephrine and an additional milligram of atropine. An ABG was drawn and CPR was started on arrival. He continued to be in an agonal rhythm. A nasogastric tube was placed for abdominal distention. Also on arrival, breath sounds were equal bilaterally.

After two rounds of epinephrine and atropine, he was shocked with 200 joules for concern for possible V-fibrillation. They got a couple of nonconducted electrical waves. This, again, turned agonal and he was shocked at 300 and 360 joules, given another milligram of epinephrine and the rhythm turned to PEA. CPR was continued and ultimately the code was called at 19:28 hours. The patient had a PEA rhythm. Blood gas returned showing a pH of 7.04, pCO2 of 77, pO2 of 5 with a saturation of 2.4 and HCO3 of 21.4.

History later determined that the patient was seen in 11/98 at the (name deleted) clinic with complaints of chest pain. He is also a known smoker and had hyperlipidemia. He is supposed to have been taking aspirin daily, but not other medications. It is unclear if he was using drugs or alcohol. Assessment: Sudden cardiac death due to terminal arrhythmia. Plan: Notify next of kin, funeral director and (information deleted).