ED Coding and Reimbursement Alert

Question: Although this chart is well documented, it appears there is nothing wrong with the patient and no treatment was given other than diagnostic testing. Can we still report an ED E/M code consistent with the documentation without a supporting diagnosis?

Kansas Subscriber

CHIEF COMPLAINT/REASON FOR VISIT: Syncope/Near syncope

HISTORY OF PRESENT ILLNESS: A seven-year-old patient presents with her parents explaining that she nearly passed out this morning. Patient got up about 6 AM to get ready for school. She had breakfast and got dressed.

Around 7 AM she was standing in the kitchen while her mother did her makeup getting ready for Halloween. While standing in the kitchen she said that her feet felt weak and lightheaded and numb and then she started to fall down and her mother caught her. Her mother explains that she looked unconscious for a few seconds. The patient did not fall to the ground and did not hit her head.

The patient has not had any signs of illness this week or this morning prior to the episode. And at this point in the interview the patient feels normal and she feels asymptomatic.

ROS:

ENT: No pulling ears, no runny nose, no sore throat
Eyes: No redness or discharge
Respiratory: No cough, no difficulty breathing
GI: No vomiting or diarrhea, no abdominal pain.
Genitourinary: No problems urinating. The patient has not started having periods yet.
Cardiovascular: No palpitations
Neuro: No seizure activity
Musculoskeletal: No pain to the extremities and no swelling
Skin: No rashes
Lymph: No swollen glands or lymph nodes
Psych: No anxiety or depression. Patient’s father explains that the environment at home was stressful this morning.

PROBLEM LIST/PAST MEDICAL HISTORY: No known active problems, and no historical problems

HOME MEDICATIONS:
No active home medications
ALLERGIES: No Known Medication Allergies
SOCIAL HISTORY:
Tobacco: Never smoker

PHYSICAL EXAM:
VITALS & MEASUREMENTS: Triage Vitals
T: 34.7 degC (Tympanic) HR: 68 (Peripheral) HR: 65 (Monitored) RR: 20 BP: 96/52 SpO2: 100%
HT: 160 cm WT: 43 kg BMI: 16.8
Current Vitals
T: 34.7 degC (Tympanic) HR: 68 (Peripheral) HR: 68 (Monitored) RR: 26 BP: 109/63 SpO2: 98%
CONSTITUTIONAL: Alert, interactive, and non-toxic in appearance. Patient lying in bed with Halloween makeup on her face.
HEAD: Normocephalic, atraumatic.
NECK: Supple without meningismus, adenopathy, or masses. Full range of motion without pain.
EYES: Conjunctivae clear, sclera anicteric. Pupils equal, symmetric, and reactive to light.
EARS: TMs clear. External canals without discharge, redness, or swelling
NOSE: No rhinorrhea.
MOUTH/THROAT: Mucus membranes moist without lesions or exudates
RESPIRATORY: Lungs clear to auscultation without distress.
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops. Normal capillary refill centrally and peripherally.
GASTROINTESTINAL: Abdomen is soft, non-tender, and non-distended without organomegaly.
LYMPH: No inguinal or axillary adenopathy
MUSCULOSKELETAL: No joint or extremity swelling. Moves all extremities symmetrically without pain.
SKIN: No rashes or lesions, skin appears normal with exception to the Halloween makeup noted on her face.
NEUROLOGIC: Normal mental status, strength, and tone, with intact cranial nerves.
REEXAMINATION/REEVALUATION: Follow-up evaluation, reveals patient has had no symptoms while here in the ER.

DIAGNOSIS: 1. Syncope, near
MEDICAL DECISION MAKING/DIFFERENTIAL DX: Near syncopal event evaluated with labs urine and chest x-ray as noted. Discussed results with parents and patient. They’ll monitor the child closely and follow up with her pediatrician. If she is experiencing more episodes she will return to the ER for further evaluation.

ED COURSE:
ADMINISTERED MEDICATIONS: No Medications Given
ORDERS:
Peripheral IV Insert
LAB RESULTS: CBC, H/H, Chem 20 and UA were ordered
RADIOLOGY: XRChest 2 Views
IMPRESSION: No acute process identified in the chest.

This report was electronically signed by

Signed By: Radiologist
EKG: HR 60 bpm

Disposition: Released to home with follow up with pediatrician

Answer: Although the results of the history and physical don’t show any active disease or injury, it does not mean there is nothing wrong with the patient. The parents are understandably concerned that their child appeared to lose consciousness for no apparent reason prior to the extensive ED workup.

The documentation supports a level 4 ED visit 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...usually the presenting problems are of high severity and require urgent evaluation…but do not pose an immediate significant threat to life or physiologic function)

The nature of the presenting problem may not reach the level of high severity listed in the descriptor for 99284.

The x-ray and EKG notes fall short of meeting requirements for a separate interpretation and report.