1. A patient comes into the ED complaining of nausea and vomiting for a couple of days. The ED physician performs a detailed history. Also supported by the documentation is an eight organ system comprehensive exam and moderate medical decision making. The ED physician's final diagnosis is acute gastritis. What E/M and ICD-10-CM codes are reported?
Rationale: The ED Physician documented a detailed history, a comprehensive exam, and a moderate medical decision making. For an ED E/M service, all three key components must meet or exceed to report the corrected ED E/M service.
The three key components in the question support 99284:
Detailed History - Meets 99284 with a detailed history.
Comprehensive Exam - Exceeds 99284 of a detailed exam.
Moderate Medical Decision Making - Meets 99284 with a medical decision-making of a moderate complexity.
The patient is diagnosed with acute gastritis. When a definitive diagnosis is determined, do not report the associated signs and symptoms (See ICD-10-CM guideline I.B.5.). In the ICD-10-CM Alphabetic Index look for Gastritis/acute referring you to K29.00. There is no mention of a hemorrhage. Verify code selection in the Tabular List.