I could use help with Emergency Dept encounters in which patients present with Chest Pain. A full cardiac workup is done, and final diagnosis is non-cardiac. Do you ever assign Level V for these situations (with the Provider's supporting documentation)? If so, given that
"the risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment."
do you ever see documentation to support a Level V when the final dx is non-cardiac and the pt is sent home?
"the risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment."
do you ever see documentation to support a Level V when the final dx is non-cardiac and the pt is sent home?