Wiki Why was I marked wrong? (Practicode Case ID: OPD7411)

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The documentation:
EMERGENCY DEPARTMENT

SEX: FEMALE

Age 70

External cause codes are NOT required.

Time Seen: 1412.

Attending Note: I personally interviewed the patient and examined the patient. I have personally reviewed the X-rays which were interpreted by the radiologist.


HISTORY OF PRESENT ILLNESS


Chief Complaint- Ground Level FALL. Location of injuries- right great toe and left great toe, rib, and a laceration of her upper lip. The injury occurred just prior to arrival. Tripped and fell to the floor over her shoes, at mom's nursing home.


(Right lateral rib pains). The patient sustained a blow to the head.


REVIEW OF SYSTEMS


The patient has had epistaxis (RT side, brief). laceration (inner aspect of upper lip). She has had chest pain (RT ribs, after fall). No fever, decreased vision, ear drainage or pain or toothache. No difficulty breathing, nausea, vomiting, back pain or neck pain. No alteration in mental status, dizziness, fainting episodes, headache or numbness. No weakness or enlarged lymph nodes.


PAST HISTORY


GERD


Additional Problems: Gastroesophageal Reflux Disease.


Medications:


Prilosec Oral 20 mg, daily as needed.


Levothyroxine Sodium Oral (Tablet 50 mcg) 1 tablet, daily.


Allergies:


No Known Drug Allergy.


ADDITIONAL NOTES


13:54 01/01/20XX Weight: 70.0 kg measured. --13:54 Brian C., RN.


PHYSICAL EXAM


Appearance: Alert. Oriented X3. No acute distress.


Vital Signs: Normal. (BP: 148 / 75. HR: 97 (regular, normal rate and strong). RR: 16 (regular, unlabored and normal). Temp: 96.8 (temporal).).


Eyes: Pupils equal, round and reactive to light. EOM intact.


ENT: No hemotympanum. No dental injury. Pharynx normal. Nose: dried nasal blood on the right side and mild tenderness. No swelling or deformity over the nose or abrasion. No septal hematoma. No malocclusion. Subcutaneous 0.5 cm laceration (inner aspect of upper lip).


Neck: Painless ROM. Non-tender.


CVS: Heart sounds normal. Pulses normal.


Respiratory: Chest wall injury: moderate tenderness located in the middle, right and lateral chest. No swelling. No abrasion. No deformity. No splinting present. No paradoxical movement.


Abdomen: No visible injury. Soft and nontender. Bowel sounds normal. No organomegaly. No mass.


Back: ROM normal. No vertebral point tenderness.


Skin: Skin warm and dry.


Extremities: Right great toe: moderate tenderness and small ecchymosis. Neurovascular intact distally. No swelling or deformity. No limitation in movement. Left great toe: mild tenderness. Neurovascular intact distally. No swelling, abrasion or ecchymosis.


Neuro: Oriented X 3. No motor deficit. No sensory deficit.


LABS, X-RAYS, AND EKG


X-Rays: Chest X-ray negative. The X-rays were interpreted contemporaneously by the radiologist.


PROGRESS AND PROCEDURES


Course of Care: 70 yo F seen for GFL, rib injury and toe pains and subcutaneous 0.5 cm laceration (inner aspect of upper lip). Was visiting her mom at nursing home. Tripped on shoes. NO preceding sxs. She is alert here, smiles, talkative, nondistressed. Consider CHI, neck injury, chest wall trauma, extremity fracture.


She is without HA, LOC, ALOC, Neck pains. She initially refused any testing on head, neck, chest or feet. I think Nasal x-ray not needed, feel fracture unlikely. She is > 65 but minor mechanism, no HA, no LOC, no ASA use. Have reviewed this and feel that head imaging not needed. NEXUS negative. She agrees to CXR to look for rib fx ptx.


15:11. Pt is in X-ray


Done with X-rays, results reviewed with her, she refused meds for home, has a few Ultram and will otherwise use Tylenol. She refused post op shoe or foot X-rays. She has been alert here, refused meds while in department. RTER precautions reviewed with pt.


CLINICAL IMPRESSION


Sprained right great toe.


Contusion to the face and chest.


Subcutaneous 0.5 cm laceration (inner aspect of upper lip).


INSTRUCTIONS


Apply ice intermittently (15-20 minutes at a time 4-6 times daily). Buddy tape toes for two weeks.


Your Current Medications: Your current home medications have been reviewed. No changes in your current home medications are recommended at this time.


CONTINUE TAKING THE FOLLOWING MEDICATIONS:


Levothyroxine Sodium Oral (Tablet 50 mcg) 1 tablet, daily

Prilosec Oral 20 mg, daily as needed.

OTC Medications:

Acetaminophen (available over the counter): take according to label instructions.

Follow-up:

Return to the emergency department severe chest pains, short of breath, fever, headache, or neck pains. Follow up with your doctor in one week. Call for an appointment.

Carol Kramer, MD

Electronically signed by CAROL KRAMER, MD 01/01/20XX

Any laboratory data incorporated in this document has been entered by the emergency clinician and may have been summarized or otherwise modified. The original full report is available in Meditech. Please refer to PCI for the Performing site information.

Jaimee Smith - Patient

Age 70 yr.

TRIAGE

Triage time 13:36 RA, patient amb to triage without difficulty. Acuity: LEVEL 4.

Chief Complaint: FALL and (tripped on her own shoes while visiting her mother's nursing home and fell).

Alert. --13:42 Carol B., RN

13:56. BP: 148 / 75. HR: 97 (regular, normal rate and strong). RR: 16 (regular, unlabored and normal). Temp: 96.8 (temporal). O2 saturation: 95 %. Alert. --13:56 Brian C., RN.

Weight: 70 kg measured. Height: 58 inches Per Patient. BMI: 32.3. --13:54

01/01/20XX Brian C., RN.

Medications

Levothyroxine Sodium Oral (Tablet 50 mcg) 1 tablet, daily. --1341 (01/01/20XX) Carol B., RN

Prilosec Oral 20 mg, daily as needed. --1341 (01/01/20XX) Carol B., RN.

Allergies

No Known Drug Allergy. --1341 (01/01/20XX) Carol B., RN.

History

Location of injuries: subcutaneous 0.5 cm laceration (inner aspect of upper lip). right big toe and left big toe. This occurred today (1030). Occurred at nursing home. Pain level now: 7/10. (right side ribs). No loss of consciousness.

Treatment PTA:

SOCIAL HX: Nonsmoker. No alcohol use. Functional assessment: no impairments noted. The nutritional risk assessment revealed no deficiencies. No report of abuse. The patient has not traveled outside the U.S. in the last 3 weeks. The patient was not exposed to tuberculosis, influenza, chicken pox or meningitis.

Arrived by private vehicle. Historian: patient. --13:42 Carol B., RN.

Interventions

13:56. ID band on patient. To waiting room. --13:56 Brian C., RN.

PHYSICAL ASSESSMENT

Alert. Oriented X 4. Appears in no acute distress. Pupils equal, round and reactive to light. Head non-tender. Neck. Head: subcutaneous 0.5 cm laceration (inner aspect of upper lip). Respirations not labored. Chest nontender. Chest wall: tenderness located in the right and left chest. Breath sounds within normal limits. Pulses within normal limits. Abdomen soft and nontender. Capillary refill less than 2 seconds. Extremities exhibit normal ROM. Neuro-vascular status intact to the extremity. Right foot: of the toe. Left foot: of the toe. Skin is warm and dry. --15:32 D., Bill, R.N.

NURSING PROGRESS NOTES

15:32. Patient returned from radiology by wheelchair with tech. --15:32 D., Bill, R.N.

15:32. Two patient identifiers checked. The plan of care for this patient has been created. Cold pack applied. Neuro-vascular extremity check. Patient gowned. Call light placed in reach. Side rails up x 2. Bed placed in lowest position. Brakes of bed on. Patient ready for evaluation. --15:32 D., Bill, R.N.

16:08. The patient reports no complaints. Overall patient status is improved (Pt discussed results with physician. Ready for d/c.). --16:08 D., Bill, R.N.

DISPOSITION / DISCHARGE

Condition at departure: improved. Patient reports pain level on departure as 1/10. No learning barriers present. Reviewed medication (Tylenol). Patient verbalized understanding. Written instructions provided in English. The patient was discharged home. The patient left the Emergency Department ambulatory.

Departure time: 16:09. --16:09 D., Bill, R.N..

The patient's home medications have been reviewed and validated by the physician. The patient's medications are listed below:

Levothyroxine Sodium Oral (Tablet 50 mcg) 1 tablet, daily

Prilosec Oral 20 mg, daily as needed.

The following medications were given to the patient in the Emergency Department:

None. --16:09 D., Bill, R.N.

Carol Kramer, MD

Electronically signed by CAROL KRAMER, MD 01/01/20XX

Doesn't the X-Ray (interpreted by the radiologist) count as independent interpretation of tests? Also, the guidelines say that fulfilling just one of the three categories in that MDM element is enough for that element to be moderate. Then combined with the prescription drug management, I thought the entire MDM would be moderate.
 
The documentation:
EMERGENCY DEPARTMENT

SEX: FEMALE

Age 70

External cause codes are NOT required.

Time Seen: 1412.

Attending Note: I personally interviewed the patient and examined the patient. I have personally reviewed the X-rays which were interpreted by the radiologist.


HISTORY OF PRESENT ILLNESS


Chief Complaint- Ground Level FALL. Location of injuries- right great toe and left great toe, rib, and a laceration of her upper lip. The injury occurred just prior to arrival. Tripped and fell to the floor over her shoes, at mom's nursing home.


(Right lateral rib pains). The patient sustained a blow to the head.


REVIEW OF SYSTEMS


The patient has had epistaxis (RT side, brief). laceration (inner aspect of upper lip). She has had chest pain (RT ribs, after fall). No fever, decreased vision, ear drainage or pain or toothache. No difficulty breathing, nausea, vomiting, back pain or neck pain. No alteration in mental status, dizziness, fainting episodes, headache or numbness. No weakness or enlarged lymph nodes.


PAST HISTORY


GERD


Additional Problems: Gastroesophageal Reflux Disease.


Medications:


Prilosec Oral 20 mg, daily as needed.


Levothyroxine Sodium Oral (Tablet 50 mcg) 1 tablet, daily.


Allergies:


No Known Drug Allergy.


ADDITIONAL NOTES


13:54 01/01/20XX Weight: 70.0 kg measured. --13:54 Brian C., RN.


PHYSICAL EXAM


Appearance: Alert. Oriented X3. No acute distress.


Vital Signs: Normal. (BP: 148 / 75. HR: 97 (regular, normal rate and strong). RR: 16 (regular, unlabored and normal). Temp: 96.8 (temporal).).


Eyes: Pupils equal, round and reactive to light. EOM intact.


ENT: No hemotympanum. No dental injury. Pharynx normal. Nose: dried nasal blood on the right side and mild tenderness. No swelling or deformity over the nose or abrasion. No septal hematoma. No malocclusion. Subcutaneous 0.5 cm laceration (inner aspect of upper lip).


Neck: Painless ROM. Non-tender.


CVS: Heart sounds normal. Pulses normal.


Respiratory: Chest wall injury: moderate tenderness located in the middle, right and lateral chest. No swelling. No abrasion. No deformity. No splinting present. No paradoxical movement.


Abdomen: No visible injury. Soft and nontender. Bowel sounds normal. No organomegaly. No mass.


Back: ROM normal. No vertebral point tenderness.


Skin: Skin warm and dry.


Extremities: Right great toe: moderate tenderness and small ecchymosis. Neurovascular intact distally. No swelling or deformity. No limitation in movement. Left great toe: mild tenderness. Neurovascular intact distally. No swelling, abrasion or ecchymosis.


Neuro: Oriented X 3. No motor deficit. No sensory deficit.


LABS, X-RAYS, AND EKG


X-Rays: Chest X-ray negative. The X-rays were interpreted contemporaneously by the radiologist.


PROGRESS AND PROCEDURES


Course of Care: 70 yo F seen for GFL, rib injury and toe pains and subcutaneous 0.5 cm laceration (inner aspect of upper lip). Was visiting her mom at nursing home. Tripped on shoes. NO preceding sxs. She is alert here, smiles, talkative, nondistressed. Consider CHI, neck injury, chest wall trauma, extremity fracture.


She is without HA, LOC, ALOC, Neck pains. She initially refused any testing on head, neck, chest or feet. I think Nasal x-ray not needed, feel fracture unlikely. She is > 65 but minor mechanism, no HA, no LOC, no ASA use. Have reviewed this and feel that head imaging not needed. NEXUS negative. She agrees to CXR to look for rib fx ptx.


15:11. Pt is in X-ray


Done with X-rays, results reviewed with her, she refused meds for home, has a few Ultram and will otherwise use Tylenol. She refused post op shoe or foot X-rays. She has been alert here, refused meds while in department. RTER precautions reviewed with pt.


CLINICAL IMPRESSION


Sprained right great toe.


Contusion to the face and chest.


Subcutaneous 0.5 cm laceration (inner aspect of upper lip).


INSTRUCTIONS


Apply ice intermittently (15-20 minutes at a time 4-6 times daily). Buddy tape toes for two weeks.


Your Current Medications: Your current home medications have been reviewed. No changes in your current home medications are recommended at this time.


CONTINUE TAKING THE FOLLOWING MEDICATIONS:


Levothyroxine Sodium Oral (Tablet 50 mcg) 1 tablet, daily

Prilosec Oral 20 mg, daily as needed.

OTC Medications:

Acetaminophen (available over the counter): take according to label instructions.

Follow-up:

Return to the emergency department severe chest pains, short of breath, fever, headache, or neck pains. Follow up with your doctor in one week. Call for an appointment.

Carol Kramer, MD

Electronically signed by CAROL KRAMER, MD 01/01/20XX

Any laboratory data incorporated in this document has been entered by the emergency clinician and may have been summarized or otherwise modified. The original full report is available in Meditech. Please refer to PCI for the Performing site information.

Jaimee Smith - Patient

Age 70 yr.

TRIAGE

Triage time 13:36 RA, patient amb to triage without difficulty. Acuity: LEVEL 4.

Chief Complaint: FALL and (tripped on her own shoes while visiting her mother's nursing home and fell).

Alert. --13:42 Carol B., RN

13:56. BP: 148 / 75. HR: 97 (regular, normal rate and strong). RR: 16 (regular, unlabored and normal). Temp: 96.8 (temporal). O2 saturation: 95 %. Alert. --13:56 Brian C., RN.

Weight: 70 kg measured. Height: 58 inches Per Patient. BMI: 32.3. --13:54

01/01/20XX Brian C., RN.

Medications

Levothyroxine Sodium Oral (Tablet 50 mcg) 1 tablet, daily. --1341 (01/01/20XX) Carol B., RN

Prilosec Oral 20 mg, daily as needed. --1341 (01/01/20XX) Carol B., RN.

Allergies

No Known Drug Allergy. --1341 (01/01/20XX) Carol B., RN.

History

Location of injuries: subcutaneous 0.5 cm laceration (inner aspect of upper lip). right big toe and left big toe. This occurred today (1030). Occurred at nursing home. Pain level now: 7/10. (right side ribs). No loss of consciousness.

Treatment PTA:

SOCIAL HX: Nonsmoker. No alcohol use. Functional assessment: no impairments noted. The nutritional risk assessment revealed no deficiencies. No report of abuse. The patient has not traveled outside the U.S. in the last 3 weeks. The patient was not exposed to tuberculosis, influenza, chicken pox or meningitis.

Arrived by private vehicle. Historian: patient. --13:42 Carol B., RN.

Interventions

13:56. ID band on patient. To waiting room. --13:56 Brian C., RN.

PHYSICAL ASSESSMENT

Alert. Oriented X 4. Appears in no acute distress. Pupils equal, round and reactive to light. Head non-tender. Neck. Head: subcutaneous 0.5 cm laceration (inner aspect of upper lip). Respirations not labored. Chest nontender. Chest wall: tenderness located in the right and left chest. Breath sounds within normal limits. Pulses within normal limits. Abdomen soft and nontender. Capillary refill less than 2 seconds. Extremities exhibit normal ROM. Neuro-vascular status intact to the extremity. Right foot: of the toe. Left foot: of the toe. Skin is warm and dry. --15:32 D., Bill, R.N.

NURSING PROGRESS NOTES

15:32. Patient returned from radiology by wheelchair with tech. --15:32 D., Bill, R.N.

15:32. Two patient identifiers checked. The plan of care for this patient has been created. Cold pack applied. Neuro-vascular extremity check. Patient gowned. Call light placed in reach. Side rails up x 2. Bed placed in lowest position. Brakes of bed on. Patient ready for evaluation. --15:32 D., Bill, R.N.

16:08. The patient reports no complaints. Overall patient status is improved (Pt discussed results with physician. Ready for d/c.). --16:08 D., Bill, R.N.

DISPOSITION / DISCHARGE

Condition at departure: improved. Patient reports pain level on departure as 1/10. No learning barriers present. Reviewed medication (Tylenol). Patient verbalized understanding. Written instructions provided in English. The patient was discharged home. The patient left the Emergency Department ambulatory.

Departure time: 16:09. --16:09 D., Bill, R.N..

The patient's home medications have been reviewed and validated by the physician. The patient's medications are listed below:

Levothyroxine Sodium Oral (Tablet 50 mcg) 1 tablet, daily

Prilosec Oral 20 mg, daily as needed.

The following medications were given to the patient in the Emergency Department:

None. --16:09 D., Bill, R.N.

Carol Kramer, MD

Electronically signed by CAROL KRAMER, MD 01/01/20XX

Doesn't the X-Ray (interpreted by the radiologist) count as independent interpretation of tests? Also, the guidelines say that fulfilling just one of the three categories in that MDM element is enough for that element to be moderate. Then combined with the prescription drug management, I thought the entire MDM would be moderate.

Your case is for the ER physician. The ER physician did not interpret the x-ray, so they do not get credit for interpreting the x-ray.

There's nothing in the documentation indicating that the ER physician looked at the x-ray films independently and made their own interpretation. They just reviewed the radiologist's report.
 
Last edited:
Your case is for the ER physician. The ER physician did not interpret the x-ray, so they do not get credit for interpreting the x-ray.

There's nothing in the documentation indicating that the ER physician looked at the x-ray films independently and made their own interpretation. They just reviewed the radiologist's report.
Isn't that what makes it independent though? According to the guidelines, it has to be performed by another physician/other qualified health care professional.
 
Independent interpretation is when a physician other than the one performing the professional component views the images/films and makes their own (independent) conclusion. While it does not need to be a full report like the radiologist performs, it does need the interpretation portion.
In this scenario, it is possible the ED doc looked at the images, but this is definitely not clearly stated. Here's what I saw regarding xray:
"I have personally reviewed the X-rays which were interpreted by the radiologist."
"X-Rays: Chest X-ray negative. The X-rays were interpreted contemporaneously by the radiologist."
"Done with X-rays, results reviewed with her,"
None of those state the physician viewed the images/films and what that physician saw.
In the ED, independent interpretations are often wet reads if the radiologist is not immediately reporting.

Examples I have seen that I would credit as independent interpretation:
"I reviewed PA & lateral CXR images from this evening. There is marked improvement in fluid collection in the left lower lobe and patient is now cleared for discharge. Final radiology read is pending."
"Images from MRI of abdomen and pelvis 1/22/23 viewed on PACS. Based on the location and size of fibroids, I recommend a laparoscopic vs vaginal approach."
"Patient's left knee MRI from last week has not yet been read. I viewed the images which demonstrates a compression fracture of the lateral femoral condyle. Will confirm with radiologist."
 
Isn't that what makes it independent though? According to the guidelines, it has to be performed by another physician/other qualified health care professional.

No. It would mean the ER physician interpreting the x-rays independently from the radiologist's interpretation.

A radiologist will always interpret an x-ray taken in the ER. The ER physician would not get credit for the interpretation work done by the radiologist.

If the ER physician did the additional work of making their own interpretation of the x-ray, that's what they would get credit for.

My radiation oncologists frequently do their own independent interpretation of MRI/CT/PET scans. It's very clearly noted in their notes that they are reviewing the imaging and giving their own interpretation, not just reading the report that was written by the radiologist. (That's not unusual in oncology - the oncologist may have a different perspective of what they are seeing on the imaging than the radiologist did.)
 
Independent interpretation is when a physician other than the one performing the professional component views the images/films and makes their own (independent) conclusion. While it does not need to be a full report like the radiologist performs, it does need the interpretation portion.
In this scenario, it is possible the ED doc looked at the images, but this is definitely not clearly stated. Here's what I saw regarding xray:
"I have personally reviewed the X-rays which were interpreted by the radiologist."
"X-Rays: Chest X-ray negative. The X-rays were interpreted contemporaneously by the radiologist."
"Done with X-rays, results reviewed with her,"
None of those state the physician viewed the images/films and what that physician saw.
In the ED, independent interpretations are often wet reads if the radiologist is not immediately reporting.

Examples I have seen that I would credit as independent interpretation:
"I reviewed PA & lateral CXR images from this evening. There is marked improvement in fluid collection in the left lower lobe and patient is now cleared for discharge. Final radiology read is pending."
"Images from MRI of abdomen and pelvis 1/22/23 viewed on PACS. Based on the location and size of fibroids, I recommend a laparoscopic vs vaginal approach."
"Patient's left knee MRI from last week has not yet been read. I viewed the images which demonstrates a compression fracture of the lateral femoral condyle. Will confirm with radiologist."
@csperoni Quick question regarding your answer. Is it completely necessary for the provider to use the word "images"? For example, if they document "CT scan without contrast did not reveal any drainable abscess. Actually, the kidney looked decreased in size suggesting improvement, some perinephric stranding, nonobstructive stones on the right." I know they viewed the images and this is their detailed interpretation-- is it enough for category 2 credit even though they didn't specifically say the word "images"?
 
@csperoni Quick question regarding your answer. Is it completely necessary for the provider to use the word "images"? For example, if they document "CT scan without contrast did not reveal any drainable abscess. Actually, the kidney looked decreased in size suggesting improvement, some perinephric stranding, nonobstructive stones on the right." I know they viewed the images and this is their detailed interpretation-- is it enough for category 2 credit even though they didn't specifically say the word "images"?
While I don't think the exact word "images" is required, it somehow needs to be 100% clear that is what took place. In the example you give, that could have been read from a report.
I would provide guidance to the provider moving forward for clearer documentation. I think "images" is one of the easiest ways to document independent interpretation. You say you "know" they viewed the images, but how would anyone reading the documentation know this? I would not count your example as independent interpretation (even though it may have actually been done).
 
While I don't think the exact word "images" is required, it somehow needs to be 100% clear that is what took place. In the example you give, that could have been read from a report.
I would provide guidance to the provider moving forward for clearer documentation. I think "images" is one of the easiest ways to document independent interpretation. You say you "know" they viewed the images, but how would anyone reading the documentation know this? I would not count your example as independent interpretation (even though it may have actually been done).

I agree. The example doesn't clearly convey that the provider reviewed the image. As worded, the provider could just be paraphrasing the radiology report and not actually viewing the imaging.

It's a good example of the old saying "if it wasn't documented, it wasn't done."
 
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