Emergency room visit

seegaye

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:confused:Could anyone help me with this:

HPI:
Pt brought in by ambulance. He is on an involuntary confinement by police. Pt was found wandering in traffic downtown. Medics suspected pt was a diabetic, he consumed a glucose tube. He is awake, alert. He does not wish to be seen by medics. His sugar got low because his whole schedule today was off, and he did not eat enough.

ED Course:
FSBS 82, pt verbalizes plan to call his brother for a ride home, pt agrees to eat a sandwich and drink a soda. Pt ambulates with smooth steady gait. Also ate a glucose tab here.

A:
Hypoglycemia

P:
Return for wrosening
 

mitchellde

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Are you coding facility or physician? do you want dx code or visit level or both?
As far as dx it is hypoglycemia. Do not code diabetes as it is suspected. for the facility it is whatever level is met for your facility assessment criteria. It does not look like a physician assessed him.
 
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mitchellde

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As I stated then code the hypoglycemic for the dx that is all you have. For the facility visit level you should have a criteria that shows what level of care to assign based on resources consumed, such as the nurse triage etc.
For the physician, the document states the patient refused to be seen by medic, so did the physician assess the patient at all? If not then you have no physician level to report.
 
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