Wiki help with e/m level

[nabernhardt]

just really wanting a 2nd opinion. the dr wants to do critical care. I dont think it is?
my opinion should have been a level 5 however documentation wise could do as level 4 not enough ROS.
52 year old male presents to the ER with chest pain, radiating down the left arm and between shoulderblades, SOB. Reports this awoke him at 0100 from sleep, wife strongly encouraged him to come in. He has no medical hx and no hx of recent trauma, surgeries, tarry stools or bleeding disorders.
Review of Systems:
Constitutional: negative
Eyes: Denies blurred vision, diplopia, and other eye problems.
Ears, Nose, Mouth, Throat: Denies dizziness, hearing disturbances, nasal congestion, and other ENT problems.
Cardiovascular: No hx of chest pain, chest pressure, palpitations, or other cardiovascular problems until tonight.
Respiratory: dyspnea
Gastrointestinal:+ nausea, no vomiting, diarrhea, constipation, dyspepsia, and other GI problems.
Musculoskeletal: Denies muscle and joint pain and swelling, and other musculoskeletal problems.
Hematologic/Lymphatic: Denies bleeding problems, excessive bruising, excessive lymphadenopathy, and other hematologic or lymphatic abnormalities.
PMH: NONE
Major Problem List:
TOBACCO USE DISORDER
Meds: None
Allergies:
NKA
FH: Father died of MI at 60
Social History:
Marital status: married
Smoking: current smoker
Packs per day: 1
.MP:TOBACCO USE DISORDER : 305.1
Alcohol: none
Seatbelt usage: Wears his/her seatbelt.
General: Alert and active. Cooperative with the exam.
Affect: anxious
Eyes: Pupils equal, round, and reactive to light. Extraocular movements intact. Conjunctive clear.
Nose: Mucosa pink. No discharge noted. Both nostrils patent.
Mouth: Mucous membranes moist.
Pharynx: Mucosa pink and moist. No erythema, exudate, or tonsillar enlargement.
Neck: Supple with no lymphadenopathy or thyromegaly.
Lungs: Quiet, regular respirations. Clear to auscultation bilaterally in all lung fields.
Heart: Regular rate and rhythm. No splitting, extra sounds, or murmurs noted.
Abdomen: Soft and nontender. Bowel sounds present x 4. No masses or organomegaly noted.
Extremities: Extremities are grossly symmetrical. Patient displays appropriate ROM without
difficulty. No cyanosis or edema noted in lower extremities.
Back: spine normal without deformity or tenderness, no CVA tenderness
Skin: good turgor, no rash or prominent lesions
Neuro: CN II-XII grossly intact. Deep tendon reflexes 2/4 in patellar and achilles tendons bilaterally.
Xray: Chest: heart normal size, no infiltrates noted, no masses.
EKG: Acute Posterior MI,
Lab: WBC 10.8 Hgb 16.9 Hct 48.2 Plt 403 Glu 151 BUN 10 Cr 1.1 Na 136 K 3.8 Cl 101 ast/alt 30/34 T.
Bili 0.52 Ca 8.8 Mg 2.30 INR 1.1 PTT
A:
Major Problem List:
TOBACCO USE DISORDER
ED:
1. Acute Posterior MI
2. Chest Pain
3. Dyspnea
P: Pt is given asa 81mg x4 PO. IV established. Ntg 0.4 mg SL without change in pain. Oxygen did the most for improving pain. TNK consent signed, risk and benefits explained. Pt agrees. Inclusion and exclusionary covered. TNK given without reperfusion. Will transfer via Air. (delay due to pilot exchange). Pt is becoming hypertensive and is border bradycardic so beta-blockers are contraindicated. Started nitroglycerin drip and Heparin bolus and infusion. Pt reperfused approximately 75 minutes after TNK.
CC Time 150 Minutes

 

[jimbo1231]

Lean toward CC

I lean toward CC on this one. It does look like an evolving heart attack with medication intervention and oxygen. Patient is both hypertensive and bradycardiac. Looks critically ill to me with appropriate intervention. I'd like to see more documentation of re evaluations and vitals; plse Ox since patient was SOB etc. etc and interventions if there were additional one's. Was monotring done?...I'm sure it was...but would like to see some documentation of that as well.

Also the 150 minutes might be questioned. Waiting for a helicoptor is not necessarily CC if they are counting that time. but I agree if not CC they needed a couple of more systems or an all other negative for a 5. But intersted in other opinions on this one. But I still lean toward being OK with CC on this one.

Jim

 

[Mojo]

Criticality of the patient (AMI), intervention (tPA, NTG and Heparin gtts) and CC time documention meet the criteria for 99291. I would not hesitate assigning critical care but I agree with Jim about the 150 minutes. I'd want to see the VS and re-evaluation documentation. With this note, I find it hard to believe that the physician provided 150 minutes to this patient alone without seeing another patient during the 2.5 hours.

 

[nabernhardt]

thank you both for your responses appreciate the feedback. feel more comfortable billing out the cc just not so comfortable billing like you said 150 minutes