ED Coding and Reimbursement Alert

Question: What E/M code would you assign to this patient with chronic back pain? She has a history of back pain, but the work up suggests the doctor is looking for something else.

Maryland Subscriber

CHIEF COMPLAINT: LOWER ABDOMINAL PAIN

Friday 11:22 am

HPI: This is a 44-year-old patient who has a history of chronic pain from a cervical disc. She comes in now with low abdominal pain all day long, rated 6 out of 10, with some sense of weakness and dizziness. She also felt lightheaded and felt that she almost fainted. She has had no nausea, no vomiting and no urinary symptoms. She states she had a reasonably normal bowel movement today. She has no history of kidney stones or diverticulitis. She states her periods are quite irregular, and she believes she is going through menopause.

CURRENT MEDICATIONS: She is on Lorcet, Soma and Zestril for hypertension.

PMH: Significant for ruptured cervical disc and chronic pain with management at the pain clinic. She also has hypertension.

SOCIAL HISTORY: She is here with her husband.

REVIEW OF SYSTEMS: As per HPI, otherwise a complete ROC is obtained.

PHYSICAL EXAMINATION:

PATIENT STATUS: A reasonably healthy woman with mild hypotension. She appears well perfused in no distress.

VITAL SIGNS: temp 99.7 Blood Pressure: 88/70. Normal pulse. Subsequent blood pressures were normal.

PATIENT STATUS:

• HEENT: Unremarkable. No jaundice and fair hydration.
• LUNGS: Clear without rales or wheezes.
• HEART: Regular rhythm without significant murmur or ectopy.
• ABDOMEN: Soft. Bowel sounds present. Very mild lower abdominal tenderness bilaterally. No guarding or rebound.
• MUSC/SKELETON: No joint paint
• INTEGUMENTARY: No rash
• PSYCH: Patients is anxious
• PELVIC: Her cervix is closed. There is no blood or pus. She has normal uterus and adnexa without masses or tenderness.
• RECTAL: Unremarkable.
• DIAGNOSTIC TEST RESULTS: White count is 18,500. Hematocrit 44. Urinalysis 1 white cell, 2 red cells and a few bacteria. Pregnancy test negative. Biochemical profile normal. Laboratory data pending is a CT of the abdomen with oral contrast.
• EMERGENCY DEPARTMENT COURSE: Patient was treated with IV fluids as well as intravenous Demerol and Phenergan. She also was placed in the CDU for observation and serial exams pending CT of the abdomen and repeat lab studies.
• ASSESSMENT: Acute abdominal pain, fever, leukocytosis, etiology unclear.
• TREATMENT/PLAN: serial exams, CT of the abdomen, surgical consultation, and close monitoring of vital signs and fever

Friday 1:47 pm

CDU NOTE

2:55 PM: exam slightly worsened and the patient is seen by the in house surgical consultant. 1 mg of Dilaudid is administered for pain

3 30: Old records ordered and reviewed, patient has a history of ruptured ovarian cyst. This is a correction on the previous dictation. Patient began her menstrual period sometime early this morning, and on pelvic examination, she had a good deal of blood at the os and in the vault. However, there was no particular uterine tenderness. At this point, she awaits her CAT scan of the abdomen to rule out any surgical condition, specifically appendicitis.

Friday 4:50 pm

CDU DISCHARGE NOTE

CAT scan was unremarkable. She had been complaining of increasing abdominal pain today without any worsening signs of really significant findings on examination.

The patient on re-examination, she had just received 50 mg of IV Demerol with some improvement in her discomfort and was going to be discharged on liquid diet. Repeat temperature is 98.6. Repeat WBC is 12,000

ASSESSMENT: Nonspecific abdominal pain.

PLAN: I will discharge her with abdominal pain instructions and advice to use Percocet as necessary for the next few days. Recheck with fever or vomiting. Otherwise, follow up with her physician on Monday.

Answer: The patient was admitted to observation until the cause of the abdominal pain could be ruled out based on CT results and repeat diagnostic studies.

This is a difficult case to diagnose because of the history of chronic pain from a ruptured cervical disk and the blood flow from menstruation. A full work up had to be performed to rule out another source of the pain. Remember that all other E/M services leading up to observation by the same provider on the same day are not separately reported, so you cannot bill both an ED E/M and the observation.

In this case, the observation was initiated and discharged on the same day so a code from the 9923X family was appropriate. A comprehensive history and physical exam is required for all but the lowest code in that family, with medial decision making driving the final code choice.

On the claim report:

99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: comprehensive history; comprehensive examination; and medical decision making that is straightforward or of high complexity)

789.00 (Abdominal pain, unspecified site)