Case Study:
Appropriately Coding Unsuccessful Treatment
Published on Tue Feb 01, 2000
To correctly code for a patient who presents in the emergency department (ED), including attempted treatments that were unsuccessful, coders must determine what, if any, procedures can be reported in addition to the overall service.
We provided the following documentation example to two expert coders and asked their opinions of the correct way to code the visit. In this case Dr. B is the emergency room physician (providing the documentation) and Dr. K is the surgeon.
Documentation of Examination and Treatment
History: This is a 79-year-old white male with the chief complaint of abdomen pain. Patient has been having abdominal pain for the past three to four days and in the past 24 hours, has had a lot of vomiting and some diarrhea. Discomfort seems worse and unrelenting. Hard to take a deep breath. Denies fevers, discomfort, congestion, trauma or otherwise contributing to his symptomatology. His medications include Isosorbide, Coumadin, K-Dur, Lasix, Verapamil, Digoxin and Lisinopril.
No known allergies.
Past Medical History: Hypotension, congestive heart failure, atrial fibrillation, shoulder pain, arthralgia and degenerative joint disease.
Review of Systems: Negative. No other contributory surgical history.
Physical Examination: Vitals were afebrile and pulse was irregular at 84-100. Respirations were 22. Blood pressure was 120/70. On examination, the patient is awake, alert, and appears uncomfortable, a bit diaphoretic and pale. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Anicteric and non-injected sclera and conjunctiva. No oropharyngeal mucosal changes. Lungs are clear. Heart is regular, maybe S-1 systolic murmur. No gallops. Abdomen is protuberant, hypertympanitic bowel sounds, diffuse tenderness, particularly the left side. He has an umbilical hernia that really does not appear to have entrapment, but he has an incarcerated left inguinal hernia which cannot be reduced at this time. His back is nontender, and the extremities are without clubbing or edema. Uncircumcised genitalia. Rectal examination is unremarkable.
Emergency Department Evaluation: Included abdominal series that showed partial bowel obstruction. Serum WBC count of 15, with left shift 15.6, hemoglobin 12.4, amylase, pro-time 30 with an INR of 2.7. Electrolytes were normal other than BUN of 24, creatinine of 1.5 and glucose of 287.
Diagnosis: Incarcerated left hernia with bowel obstruction.
ED Management and Disposition: The initial attempt at reduction was unsuccessful and the patient was subsequently placed in Trendelenberg under conscious sedation with morphine and Versed. After multiple attempts of incarceration, the bowel was reduced into the peritoneal cavity again, leaving a large vacant left inguinal hernia. Subsequently, he was discussed with Dr. K who evaluated him here in the emergency department, and then he was admitted to the step-down unit for further intervention and evaluation. He was treated with multiple meds here in the department [...]
