Initial hospital care

stgregor

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Tacoma, WA
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Hi there,

I don't have much experience coding E&M, but I am faced with needing to code an H&P for a hospital ICU admission performed by a cardiologist. I know I am going to be choosing from the 99221 - 99223 series of codes, and I've reviewed the E&M documentation requirements. I don't think this qualifies for a 99223, but I'm not sure which of the other two codes to choose. Any assistance would be greatly appreciated! Thanks!

The patient is being admitted to intensive care unit today.
HISTORY: The patient is a 78-year-old Caucasian male with history of
hypertension, but with no previous cardio history, who developed sudden spontaneous chest pain, nausea and vomiting while at home and starting at approximately a.m. today. The patient was brought by paramedics to the emergency department and was found by EKG to be having an acute inferior wall myocardial infarction of approximately one hour duration. The patient was
admitted emergently with expedited transfer from the emergency department to the cardiac catheterization laboratory for primary PCI for management of an acute inferior STEMI. As mentioned, the patient has no previous cardiac history.
PAST MEDICAL HISTORY: Noteworthy for hypertension and the patient also reports a history of a stricture in his aorta, but no office records are available. The patient also has a history of prostatism treated with Avodart.
HOME MEDICATIONS: By the patient's report include:
I. Atenolol, dose unknown, but thought to be 50 mg daily.
2. Vitamin E 400 units daily.
3. Avodart I tablet daily.
SOCIAL HISTORY: The patient is retired. The patient denies tobacco or substance abuse.
Only risk factors for coronary heart disease are a history of hypertension.
FAMILY HISTORY: Negative for premature or generalized vascular disease.
REVIEW OF SYSTEMS: Negative for prior episodes of chest discomfort, palpitations, lightheadedness, syncope, cough, fever, sputum production, hemoptysis, hematemesis, melena, abdominal pain, nausea, vomiting, or diarrhea, or any bleeding diaphyses. It is also negative for any symptoms to suggest transient ischemic attack or stroke. Remainder of the review of systems is noncontributory.
PHYSICAL EXAMINATION: The patient is currently nauseated and having emesis while encountered in the cardiac catheterization laboratory. Blood pressure is 80/50, pulse 41 in sinus bradycardia with first degree AV block. In the supine position, the jugular venous pressure is difficult to assess, but grossly elevated. The thyroid gland is supple. Lungs are clear without rales
or wheezes. Precordial examination reveals normal S1 and S2, bradycardic rhythm, but no abnormal murmurs, gallops, or rubs at this time. Abdomen is soft, benign, and nontender. The femoral pulses are normal. The distal lower extremities are cool, but otherwise without evidence for emboli or edema. Skin examination is grossly normal. Ears, eyes, nose, and throat examinations grossly normal. The neurologic is grossly intact and the patient is alert and oriented x3. Rectal examination deferred given acute infarct setting.
12-lead electrocardiogram shows classic inferior myocardial infarction with ST elevation in the inferior leads. There is no significant reciprocal change. Sinus bradycardia with first degree block noteworthy.
ASSESSMENT: This patient presents with an acute spontaneous inferior wall myocardial infarction of one hour duration. The patient has been brought to the cardiac catheterization laboratory emergently for management and with emergent cardiac catheterization and percutaneous coronary intervention as needed. The plan is to proceed emergently with cardiac catheterization and intervention quickly as possible.

ADMITTING DIAGNOSES:
I. Acute inferior wall myocardial infarction.
2. History of hypertension.
3. History of prostatism.
4. Ill-defined history of abnormality.
 

ARCPC9491

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Hi! Here's what I come up with:

History
HPI: 4+
ROS: 6
The statement "Remainder of the review of systems is noncontributory" does not count as a complete review of systems.
PFSH: 3/3

OVERALL HX: Detailed

Exam
8 organ systems reviewed. (I used '95 guidelines)

-Constitutional
-Ears, Nose, Mouth, Throat
-Cardiovascular
-Respiratory
-Gastrointestinal
-Musculoskeletal
-Skin
-Neurologic

OVERALL EX: COMPREHENSIVE


MDM

Presenting Problems: New Problem, Work up Planned 4 points
Data: Review/order medicine test (Cath, EKG) 1 point
Risk: High

OVERALL MDM: High

History = DETAILED
Exam = COMPREHENSIVE
MDM = HIGH

Overall level for me is 99221.

In this note, the only item that prevented a 99223 is the ROS in the history. If the physician had reviewed the other systems and said they were negative - this would have allowed for a complete ROS, making the overall history comprehensive and the level for this admission would have been 99223.
 
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4,466
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Milwaukee WI
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Too bad there's no critical care time documented

If the MD had documented that s/he spent 30 minutes or more in direct critical care you could bill 99291 ... but s/he didn't ... S I G H

This would be a good opportunity to educate the physician about
1) wording on "remainder of systems reviewed and negative"
2) documenting time for critical care

S/he is cheating him/herself with the documentation as written.

F Tessa Bartels, CPC, CPC-E/M
 
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