ED Coding and Reimbursement Alert
Avoid Complaints From The Chief Over Your HPI Documentation
Question: Can I get others’ opinions on chief complaint and number of elements in this HPI?
Per EMS, patient’s family called 911 because she has not been eating or drinking for the last week, worried that the patient may be dehydrated. Patient with known metastatic breast cancer having chosen to avoid aggressive treatment of same. Patient states she is in no pain, no nausea, thinks that he/she has been eating and drinking enough and not sure why family called 911.
Answer: This is a difficult case because there does not appear to be a chief complaint. Dehydration seems to be the best choice here. As far as the HPI goes, we have duration (not been eating or drinking for the last week), context (Patient with known metastatic breast cancer having chosen to avoid aggressive treatment of same), and associated signs and symptoms (Patient states she is in no pain, no nausea). Three elements of HPI would qualify for 99283 (Emergency department visitfor the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination and medical decision making of moderate complexity…), which would need to be potentially adjusted depending on the rest of the clinical course.
Pennsylvania Subscriber
ED Coding and Reimbursement Alert
- Regulations:
Will Your Compliance Plan Make the Grade? Find Out What The ACA Requires
CMS is dragging its heels in creating guidelines. Here’s expert advice on what to do [...] - Coding for Transports:
Steer Clear Of Trouble When Reporting Transport Services
You can separately report transport services if the code conditions are met. Patients in the [...] - Coding Strategies:
Listen Carefully to These 4 Tips For Recouping Cerumen Removal Pay
Why you’ll get denied if you report 69210 more than once per episode. Patients often [...] - Keep Track of These Face-to-Face Services RVU Stats
Face-to-face services pay much better than supervision by radio. Check out the RVUs and payments [...] - You Be the Coder:
Don't Be Blind To Reporting An E/M Code With An Eye FBR
Question: I would like to know what other ED coders would assign for this ER [...] - Reader Question:
Avoid Complaints From The Chief Over Your HPI Documentation
Question: Can I get others’ opinions on chief complaint and number of elements in this [...] - Reader Question:
Bill Critical Care Under One TIN
Question: Our ED physician saw a patient in the morning for a critical care service. [...] - Reader Question:
The Past Is History, So Let's Examine The Present
Question: How should we count allergy status in determining E/M levels? The ED physician notes [...] - Reader Question:
Do Some Diagnostic Testing Of Your EKG Documentation
Question: When billing for an EKG interpretation, am I correct in thinking that there must [...] - Check What the ACA Says About Compliance Programs
Review the following directive from the Affordable Care Act creating the requirement for formal compliance [...]
