ED Coding and Reimbursement Alert

Question: Other coders and I disagree about this chart:

ED NOTE:

CHIEF COMPLAINT/REASON FOR VISIT: Fever
HISTORY OF PRESENT ILLNESS: This 4-year-old male patient comes to the emergency department with the chief complaint of fever which has been present for two days. The associated symptoms include congestion decreased oral intake and weight loss of two pounds over the past month and have been constant. The patient has no sick contacts. The patient has had similar symptoms previously when he was treated for strep throat last month. The patient has not recently seen his doctor and has not been hospitalized or treated for this similar illness during this period. Historians are his mother and grandmother. They are concerned about dehydration and possibly diabetes in addition to the source of his fever.

ROS:

CONSTITUTIONAL: Positive for fever as per history of present illness. Denies night sweats. Positive for weight loss of 2 pounds over the past month
HEENT: Denies headaches or dizziness.
CARDIOVASCULAR: Denies chest pain.
RESPIRATORY: Denies dyspnea, coughing, or wheezing.
GASTROINTESTINAL: Denies abdominal pain or discomfort. Positive for nausea and vomiting ×1 this morning after crying. Denies constipation or diarrhea.
GENITOURINARY: Denies pain with urination, denies frequency.
INTEGUMENTARY: Denies rashes or skin lesion.
MUSCULOSKELETAL: Denies muscle aches, denies joint aches or pains.
EXTREMITIES: Denies trauma.
NEUROLOGIC: Denies numbness or tingling
PSYCH: Denies any symptoms, well behaved
PROBLEM LIST/PAST MEDICAL HISTORY: Conjunctivitis Inclusion cyst
Historical: Circumcision, No known active problems
HOME MEDICATIONS: No active home medications
ALLERGIES: No Known Medication Allergies

PHYSICAL EXAM:

VITALS & MEASUREMENTS: Triage Vitals
T: 38.5 degC (Tympanic) HR: 164 (Peripheral) RR: 34 BP: 134/76 SpO2: 96%
HT: 96 cm WT: 11.7 kg BMI: 12.7
Current Vitals: T: 38.5 degrees C (Tympanic) HR: 126 (Peripheral) RR: 24 BP: 126/82 SpO2: 98%
CONSTITUTIONAL: Alert, interactive, and non-toxic in appearance.
HEAD: Normocephalic, atraumatic.
NECK: Supple without meningismus or masses, positive for anterior cervical lymphadenopathy. Full range of motion without pain.
EYES: Conjunctivae clear without injection, hemorrhage, discharge, or icrterus. No eyelid swelling or redness. Pupils equal, symmetric, and reactive to light.
EARS: TMs clear with normal landmarks and no erythema. External canals without discharge, redness, or swelling
NOSE: Patent nares without rhinorrhea.
MOUTH/THROAT: Gingiva, tongue normal but the posterior oropharynx is erythematous without exudate.
RESPIRATORY: Lungs clear to auscultation without retraction, grunting, or flaring with the exception of some rales that are present in the right lower lobe.
CARDIOVASCULAR: S1 and S2 are normal with regular rate and rhythm and no murmurs, rubs, or gallops. Normal femoral pulses with capillary refill time less than 2 seconds peripherally and centrally.
GASTROINTESTINAL: Abdomen is soft, non-tender, and non-distended without rebound, guarding, or masses. Bowel sounds are normal. No organomegally.
LYMPH: No inguinal or axillary adenopathy.
MUSCULOSKELETAL: Spine, ribs and pelvis are non-tender and normally aligned. Extremities are nontender and show full range of motion without pain. There is no clubbing, cyanosis, or edema.
SKIN: No rashes, purpura, petechiae, ulcers, swelling or other lesions.
NEUROLOGIC: Symmetric use of extremities without weakness. Normal gait. Lower extremity reflexes are symmetric with down-going toes. No clonus. Cranial nerves are intact with normal tone and strength. Patient exhibits age-appropriate affect, behavior, and interaction.

REEXAMINATION/REEVALUATION: Nontoxic appearing.

DIAGNOSIS: 1. Pharyngitis 2. Streptococcosis 3. Febrile illness 4. Dehydration
MEDICAL DECISION MAKING/DIFFERENTIAL DX: Patient has had a fever up to 103. He has had a history of strep throat which was recently treated and has a Centor score of 4 currently. His rapid strep was negative but I wanted to get a culture and so that is pending. We will go ahead and treat him with amoxicillin for his erythematous oropharynx A chest x-ray was obtained because of some rales that I heard which were mild in the right lower lobe. The chest x-ray shows no acute abnormality. His grandmother, who has medical knowledge, is also concerned about the possibility of diabetes. We have therefore done a blood sugar which came back at 80. At this point we will discharge the patient to follow-up with his primary care physician. He is drinking adequately and shows mild dehydration. I did offer the family IV fluids but we’ve decided to instead try oral rehydration which has worked here in the emergency department. The patient is ready now for discharge with his very reliable family and to follow-up with primary care physician. Return precautions were provided.

ED COURSE:

ADMINISTERED MEDICATIONS:
Acetaminophen: 165 mg (10/31/16 09:32:00)
Ondansetron: 1 mg (10/31/16 08:36:00)

LAB RESULTS:

Chemistries
Whole Blood Glucose: 80 mg/dL
Rapid strep reportedly negative sent for culture
IMAGING: XR Chest 1 View Frontal
10/31/16 08:25:32

IMPRESSION: Hyper inflated lungs. No other acute process identified in the chest.
This report was electronically signed by
Signed By: Dr. X
Disposition:

PRESCRIBED MEDICATIONS THIS VISIT:

AmoxixicllinTime Seen:
10/31/2016 07:54
Information entered by XXXX acting as scribe for EDMD.
What should I report?

Ohio Subscriber

Answer: The history and physical exam both justify a detailed level required for assigning 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity…).

CPT^® includes this Clinical example in Appendix C - “ED visit for a well appearing 8 year old who has a fever, diarrhea, and abdominal cramp; is tolerating oral fluids and is not vomiting.”

Note the diagnoses of dehydration and high fever, along with the cultures ordered. These “diagnoses and treatment options considered” do transcend the threshold for moderate complexity shared by both 99283 and 99284.

This presentation is more than a cold, the final diagnosis pharyngitis, strep and dehydration with abnormal vital signs and a broader differential diagnosis with weight loss create an urgent nature of the presenting problem more consistent with the level 4 choice.