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Wiki Critical care or E/M

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JRC

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Hi,

Iam quite confused coding this document?

" Dr was in the Intensive Care Unit when Code Blue was called. Nephrologist has just finished dialysis. The patient had been hypotensive during the dialysis. A CPR was initiated. she was ambubagged. She has been on the ventilator via tracheostomy. Epinephrine was given. The CPR was continued. She remained asystole, subsequently had coarse ventricular fibrillation. She was cardioverted. Epinephrine was also repeated. Atropine was also given. A Code Blue was called off at 5:30 p.m. She was pronounced dead at 5:30."

Place of service : Inpatient hospital

Critical care time was not documented in the report.
Dr has provided CPR.Iam not sure about the E/M to be coded.
Any help on this would be greatly appreciated.

JRC :confused:
 
I don't see a note by a provider so I don't see an E/M at all. This does not appear to have been written by a provider of service in this case.

Laura, CPC, CEMC
 
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