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Thread: Hematemesis

  1. #1
    Join Date
    Apr 2007

    Default Hematemesis

    AAPC: Back to School
    I know I shouldn't be questioning a doc on if a situation is critical care or not b/c I am not a doc....but I am having a hard time wrapping myself around what exactly is critical care. I have read the cpt description 1000x plus. I get if there is failure and what not but can if a doc is called on a pt that has no other symptoms other than hematemesis, is this critical care. Actually the pt was stabilized prior to the doc arriving. Please help me understand this sensitive code better. Does anyone have more specific guidelines that they follow for critical care other than cpt?

  2. #2
    Join Date
    Apr 2007

    Default Another Critical Care Question

    I have a note that I would like to post that is critical care...again, please help me clarify that this is a critical care visit. thank you.

    Chief Complaint/HPI
    Patient is a 65 yr old M presents to MD office this am with c/o feeling dizzy. While at home he reached to turn the stove on felt dizzy and felll down with no true LOC and got him concerned and went to MD office. In MD office BP low so sent to ER. Initially on admit Bp was 70 systolic improved with fluuid challenge. feels less dizzy now. No chest pain, SOB, palpitation sweating through this episode. drinks regularly heavy and r/o withdrawal. Last drink 2 days ago and today had 2 loose BM watery to semi formed. No problems urinating and did urinate prior to going to MD office. No fevers,cough,phelgm. Chronic erythrema of umbilicus treated with out[pt antibiotics by MD in july

    Past Medical History
    Alcoholic active and a member of AAA
    Abdominal aorta anuerysm
    H/o anginal s/s not recently with ABn stress test
    HTN history
    CKD baseline creatinine 1.7
    h/o alcoholic pancreatitis
    active tob user
    Active tob user


    Home Medication

    Home Reported Medications
    Allopurinol 300 Mg Tablet (Allopurinol) 300 Mg PO DAILY
    Lotensin 10 Mg Tablet (Benazepril HCl) 10 Mg PO DAILY
    Elavil 25 Mg Tablet (Amitriptyline HCl) 25 Mg PO DAILY
    Ambien 10 Mg Tablet (Zolpidem Tartrate) 10 Mg PO HS PRN
    Aldactone 50 Mg Tablet (Spironolactone) 50 Mg PO BID
    Lasix 40 Mg Tablet (Furosemide) 1 Tab PO DAILY
    Martinic (Vitamin B12-Intrinsic Factor) 1 Cap PO DAILY
    Prilosec 20 Mg Capsule (Omeprazole) 20 Mg PO DAILY
    Potassium-99 (Potassium) 99 Mg PO DAILY
    Folic Acid 1 Mg PO DAILY
    Cephalexin 500 Mg Capsule (Cephalexin Monohydrate) 500 Mg PO Q8H
    Ecotrin 325 Mg Tablet (Aspirin) 325 Mg PO DAILY

    Coded Allergies:
    No Known Allergies (Verified , 7/2/08)

    Social History
    active alcohol and an alcoholic at r/o withdrawal
    active tob user 11/2 PPD
    denies drug use

    Family History
    non contributory

    Review of Systems
    refer to hpi

    Physical Examination
    vitals noted
    S1,S2 + RRR
    B/l AE decrterased but no adventitious sounds
    Soft, NT BS + with erythrema umbilicus chronic does not seem like source of infection
    AAO X3
    no edema

    Clinical Data
    Vital Signs Temperature: 96.6, Heart Rate: 89, Respiratory Rate: 20, BP: 85/46, Pulse Oximetry: 99
    All data reviewed in the EMR.


    Hypotension of unclear etiolgy r/o sepsis r/o MI
    Alcoholic at r/o withdrawal mild s/s now
    Hepatitis ? acute vs chronic
    H/o Abn stress test
    H/o AAA
    h/o HTN

    ivf, pan cultures and antibiotics
    renal US and foley's with strict I/o
    CE X3, echo and consult cards
    alcohol withdrawal protocol and consult BHU
    critical care time spent 45 min

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default I don't think so

    First I'm not sure if this is an admission note or an ER visit.
    I am also NOT a doctor or a nurse, so maybe I'm missing something.

    Well, the doctor lists ARF in impression ... normally I'd say acute renal failure would probably get a patient classified as critically ill. But I don't see any evidence of exam of kidneys or renal system to get to this diagnosis. (I know he orders a renal US.)

    Acute alcohol withdrawal might also result in a patient being critically ill ... but this patient is alert and oriented x 3, seems to have pretty good vitals (albeit low BP). Not sure how he was getting around, but it sounds like he took himself to the PCP and probably took himself to the ER (or did he arrive by ambulance?).

    In total, the patient just doesn't "sound" critically ill and in great distress.

    I would not code it as critical care. If this is the ER physician, I'd stick to the ER codes. (Of course then he's got to do a better job of getting his history elements in order to qualify for the higher level of codes.)

    What do others think?

    F Tessa Bartels, CPC, CEMC

  4. #4
    Join Date
    Apr 2007


    I agree, I don't see critical care here either.

    I have a problem when they have all the elements of E/M, critical care is just that, critical. They aren't capturing all this info, they are making decisions to keep the patient alive and functioning. This patient may be critically ill, I'm not clinical either, but it doesn't appear he is in any immediate danger based on this note.

    Hopefully one of the nurse auditors will chime in as well.

    Laura, CPC, CEMC

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