Wiki 2023 ED documentation

[RABBIT2020]

the patient presents with palpitation no previous cardiac condition nor never experienced this palpitation before.
Exam shows occasional abnormal rhythm.
the provider documents - moderate problem with exacerbation

data were 3 labs and and ekg interpreted. extensive

Patient given normal saline and dc. low

The supervisor insists the problem is high and the level is 99285.

from a compliant view does this rise to a high level in the Emergency room?

 

[kdlberg]

How was the EKG interpretation billed? If a cardiologist interpreted it (and billed the professional component) but then the ER doc looked at it and documented their own interpretation, you've met the data requirements for 99285.
Presenting problem moderate with exacerbation is considered moderate risk, not high risk. (if it was chronic with severe exacerbation, that's high risk.) What, exactly, was the final dx? IF it's something that can fit in the "High" category," then 99285 is supported. Otherwise, it has to come down to 99284.

 

[RABBIT2020]

How was the EKG interpretation billed? If a cardiologist interpreted it (and billed the professional component) but then the ER doc looked at it and documented their own interpretation, you've met the data requirements for 99285.
Presenting problem moderate with exacerbation is considered moderate risk, not high risk. (if it was chronic with severe exacerbation, that's high risk.) What, exactly, was the final dx? IF it's something that can fit in the "High" category," then 99285 is supported. Otherwise, it has to come down to 99284.

No acute pathology found. Final dx was palpitation. The Ekg was done in the ER department and counted as independent interpretation of tests cat 2. thank you for your response.