Wiki audit tools & level 5 assignment

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dvanhaneghan

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I have a question. My supervisor and team leader are telling me that the audit tool is just that, a tool. So, if I have a patient come to the ED and the documentation meets all the criteria for a level 5 visit according to the audit tool they are telling me that I still may not be able to code it as a level 5. Here is a scenerio.

Patient comes in with left arm numbness that lasted 45 minutes. The physician does a complete HPI, ROS, PFSH, and EXAM. Patient has co-morbidities of diabetes, CAD, hypertention, and hypercholesterolemia. The patient did not have any associated chest pain, shortness of breath, or diaphoresis. Physician orders, EKG, Labs, and x-ray. He also asks for old records. He discusses the case with the radiologist and also speaks with a cardiologist.

The patient is sent home in stable condition to follow-up with the cardiologist in the morning after having 2 negative troponins. Patient was not given any medications.

How would you code this?
 
That is a good question. The audit tool is a "tool" and I use it daily. You have to consider the results of the tests ordered, and if any stabilizing medications had to be given and how they were administered. Were any pain medications given, perscriptions at discharge? Also, sometimes if everything fits a certain level according to the tool guide, but just needs a push to go from say, a 4 to a 5, go back to your presenting symptom and decide if it was severe enough to fall under "high" severity. Also, make sure the MDM points were given appropriately.
If everything was normal, and no additional treatment was needed, that sounds like a moderate level, albiet a very strong level 4. I would want to give the physician a level 5 too, but having just taken the CEDC exam I found that the guidelines are more strict than I thought.
Bottom line, whatever level you chose, be sure you have valid reasons for selecting it and can back it up with documentation.
I hope this helps!
 
Lean toward a 5

I agree with the comments of PHerald. Sometimes a coder can "Count to a 5" based on documentation but the 5 just isn't there based on medical necessity. Important in that determination is Nature of Presnting Problem and Chief complaint. Since ED docs typically don't have a patient history available immediately, the NOPP will drive evaluation and management and MDM. Although it isn't an essential audit element it has a lot of influence in Emergency Medicine.
This is a borderline one. But my leaving would be toward a 5. The patient does have a significant chief complaint and a complex history. And it looks like a full Cardiac work up was done(depending on the labs) Also it looks like a new patient as they ussually are in the ED with additional w/u planned. The patient being sent home doesn't help. But shouldn't elimimate a 5 if all of the elements are met. But I agree with ph in wanting to see some more documentation for final decision.

JIM S
 
Our ED docs agree that MDM could be considered higher when sending a patient home after workup for chest pain with the co-morbidities you mentioned, as it could be more of a risk to decide not to hospitalize. Just because the patient goes home doesn't mean the MDM wasn't high.
 
I have to agree with Pherald. I don't think a Level 5 is appropriate (given the info you provided). If they decided to place him in OBS or something based on the co-morbidities, I can see the Level 5 being applied. Logically...Home, w/o meds, and only presenting complaint being left arm pain....No SOB or CP noted...I'd say 4.
 
Borderline

I agree, no meds and being sent home leans it to 4. But this patient has a complex history so arm numbness for 45 minutes is a significiant symptom. And I wouldn't downcode only because the patient was discharged since it appears that additional workup is planned with a cardiologist. Anyway, would need to see more. But the level of service debates make coding interesting!

Jim
 
Level 4 or Level 5 depends on everything. When I say everything I mean everything. I work as an ED Chart Abstractor and I'm also a CPC-A. I'm not sure how everyone else abstracts the charts, but everything is given points. If they arrived by Ambulance that is points, how many times their vitals were checked, the types of meds given, tests done, any procedures the physician had to do, were they admitted or discharged. Some cardiac meds fall under critical care, and right there are a bunch of points; which would definitely make it a Level 5.
 
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