Wiki E/m level er

[nabernhardt]

I have an ER and I put it as a level 4 because I wasn't sure if it would qualify as the acuity for level 5 and didn't think the documentation met a level 5. Also couldnt do CC no time documented. But I am not definete that I have the correct level and would like 2nd opinions please. I am trying to learn E/M coding better so any helpful hints too.

S: 31 years old female presents to the ER via EMS actively seizing. Husband reports that she has been dealing with a bad abcess to her teeth and gum for the past week, today it significantly worsened in intensity. She has had the chills and fever, pain going into the side of her face and neck. She was not on antibiotics and has not seen anyone. He went out for food at 6 pm and when he returned she was on the couch in a seizure. EMS initiated IV and nasal flute with no gag reflex, on NRB with manual airway control. Pt unable control airway. Eyes deviating downward.
Review of Systems:
Unresponsive
O:
General: Actively seizing
Eyes: deviated down and non-reactive pupils at 2 mm.
Nose: Mucosa pink. No discharge noted. Both nostrils patent.
Mouth: Mucous membranes moist. l
Pharynx: Large amount of secretions.
Lungs: Coarse breath sounds bilaterally.
Heart: Regular rate and rhythm. No splitting, extra sounds, or murmurs noted.
Abdomen: Hypoactive no masses.
Extremities: Clinched with tonic clonic motions.
Neuro: active seizure
Xray: CT Head Normal, CXR shows ETT slightly R mainstem.
Lab: Serum Preg NEG WBC 21.8 Hgb 16.8 Hct 51.1 Plt 374 Glu 124 BUN 7 Cr 1.0 Na 138 K 3.1Cl 100 ast/alt 31/57 t. bili 0.74 Ca 9.0 TSH 2.46 Tylenol 0.00 UDS + Methadone and OpiatesABG: pH 7.36 pCO2 50.0 pO2 81 CO2 30 H2CO3 1.5 Urinalysis: pyuria
P: Pt has second line established. RSI is performed with Propofol 150 mg IV, Succinylcholine 100mg and 7.5 ETT placed. Followed with Pancuronium 8 mg IV. Placed on vent and ran by respiratory. CRNA to intubate with EMTP student. CRNA supervised intubation. NG tube placed and suction clear yellow stomach fluid. Foley placed with clear yellow urine. Versed 5 mg IV. CXR and CT performed. Rocephin 1 gm IV and Vancomycin 1 gm IV> Contact RWMC hospitalist (Dr. sreekantan) who accepts the patient and wishes patient to have zosyn also IV. 3.375 gm IV given. Repeat dose of pancuronium 4 mg IV and versed 5 mg IV. At 2230 pt given 4 mg pancuronium and 10 mg versed. Pt care turned over to Air Care flight crew.

 

[jimbo1231]

Could be CC with Time documented

There is certainly enough going on in terms of patient condition, actively seizing and unresponsive etc. and intervention by providers to qualify for CC. The patient was seizing and is now unresponive. These were multiple IV interventions, ET intubation, NG etc.
This chart might be worth returning to te physician highlighting why it looks clinically like CC and asking if the physician provided 30 minutes. Also be clear about the elements that can be counted toward CC time.
Coding a 5 could be a bit problematic. Overall it's a good chart but lacks 2/3 elements of SH/FH and PMH. The physician noted the patient was unresponsive and actively seizing which I think gets you part of the way to the history caveat. But I'd like for some more documentation...like due to unreponsiveness complete history could not be obtained. This could also be an issue for physician education about chart completion. Also there might be some procedures that can be coded, but the chart doesn't make clear whether the physician did or closely managed the procedures.

Jim