ED Coding and Reimbursement Alert

Question: The chart documentation seems a little brief, but this seems like a pretty sick patient. What E/M level would you assign to this chart?

Ohio Subscriber

Chief Complaint: Shortness of breath

HPI: This 58-year-old male patient presents complaining of shortness of breath of gradual onset, but increasing severity over the past two days. He says the pain is severe and it is worse upon movement. He reports no change when lying flat or with rest. He is positive for dyspnea at rest, cough, malaise, and fever. He denies any abdominal pain, anxiety, dizziness, nausea, numbness, or diaphoresis. He reports a history of asthma and pneumonia, but no angina or coronary disease. He is Hep C positive s/p interferon.

Review of Systems: Except as noted above or elsewhere in the record, all other systems are negative.

Exam: 

Constitutional: mild distress, patient is alert and WDWN

Cardiovascular: Tachycardia, capillary refill time

Musculoskeletal/Extremities: Non tender, normal ROM, no pedal edema or calf tenderness. NVT intact

Respiratory: In respiratory distress, no wheezing, rales and rhonchi on right side, diminished BS, right side

GI/Abdomen: Soft non-tender, no organomegly, no pulsatile mass. Normal bowel sounds.

ENT: External inspection normal, TM's clear, pharynx normal, teeth normal

Integumentary: Color normal, warm and dry, no rash

Eyes: PERRL, lids and conjunctiva are normal on exam

Neuro: Oriented X 3, cranial nerves II-XII within normal limits, No motor or sensory deficits

Procedure: Central line is required for emergency intravenous access. Patient placed in Trendelenburg position and prepared for right internal jugular line insertion. Landmarks were identified and the insertion site was draped and prepped in a sterile manner. Lidocaine was used to anesthetize the site. The needle was inserted lateral to the carotid artery and slowly advanced, aspirating all the way, until the vein was entered. 

Once inside the vein, the syringe was removed and a guide wire was inserted through the needle and advanced. The needle was removed and the dilator was inserted over the guide wire, the dilator was pushed into the skin and then removed. The central line was then inserted over the guide wire, and when in place, the guide wire was slowly withdrawn until the wire tip appeared from the line port. The central line was then inserted and the guide wire completely removed. The line was sutured into place and a dressing was applied. Placement was confirmed by x-ray. Central line insertion was successful on the first attempt. There were no complications associated with the procedure and the patient tolerated the procedure well.

Ultrasound guidance for central line placement. Ultrasound guidance in real time is utilized for placement of right internal jugular. Marked respiratory variation in IJ volume likely from volume depletion. Placement of needle visualized by ultrasound. Good blood return also noted. Images archived.

Progress Notes: Discussed with consultant and patient will be admitted for more care

Diagnosis: Pneumonia, dyspnea, and sepsis

Answer: The History of Present Illness (HPI) documenting needs to be in the provider's own words, but otherwise you can draw elements of ROS, PFSH and MDM from elsewhere in the chart. There is no requirement that these other documentation elements be listed under separate headings and remember that ROS and PFSH can be recorded by ancillary staff as long as there is a note that it was reviewed by the physician reporting the service. Although this case sounds like a level 5 presentation, with only one of the three PFSH, past medical history in this case, documented the code choice defaults to a level 4 ED E/M code without a caveat statement from the physician.

On the claim, you would report:

• 99284-25 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity...)
• 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older)
• 76937-26 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting [List separately in addition to code for primary procedure])
• 481 (Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia])
• 995.91 (Sepsis)
• 786.05 (Shortness of breath)