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Established E&M?

  1. #1
    Post Established E&M?
    Exam Training Packages
    This is a bit lengthy but necessary. Patient was scheduled for surgery however, surgery not carried out and physician wants to bill a level of E&M. I'm having a hard time pulling out components to bill and E&M or even the diagnosis to use. PLEASE HELP!---No mention of time spent and should note H&P from mentioned visit was comprehensive.

    The patient did present this morning and was cleared medically by Family doctor. Patient did come in this morning and history and physical are reviewed and are unchanged from his March 3rd note. The patient however was evaluated by anesthesia and briefly by ENT. They did not feel that the patient could be put to sleep under general anesthesia because of concerns about the airway and general overall comorbidities. The patient did have an attempted procedure under just sedation previously and would not tolerate this. He became short of breath even head was elevated only about 30 degrees. Currently after nebulizer treatment his lungs are clear with increased expiratory phase, heart is regular. He does have the lesion on his left rib which is bony and hard. He also has a lesion on his left neck which is unchanged. He has increased upper airway soft tissues. Sclera anicteric. He does have the macular degeneration. His heart is regular. His abdomen is benign. Looking at his periphery he does have some IV sites. The anesthetist did evaluate the patient, did not think he was a candidate for being put to sleep under general anesthesia. Apparently there were discussions with ENT who did not think that a surgical airway would even be possible if they were unable to get an airway while putting him to sleep. The patient cannot tolerate lying flat in order to have this put in. I did review this with the patient and his family. I also discussed this by phone with Dr. With this being the case it is the opinion of everybody that it would be best to try to place a PIC line in his antecubital and thread this centrally. This would negate any risks to nicking his lung which would cause pneumothorax and would have a high risk of being fatal in this gentleman. It would negate the risks of airway concerns and general anesthetic. All were in agreement. I did discuss this and will set up a time for the patient and have him treated with a PIC line. Patient was then set up and was having trouble breathing at 30 degrees but with sitting both upright was much better. Will consult PIC line service. CT and other films were evaluated and the patient in December did have a lesion on the third rib where he now has a much larger lesion. He also has radiation injury to his right neck and apersistent mass. Placement of a right neck is therefore not possible and is complicated by radiation injury. Placement of a right subclavian was also complicated by radiation. Left subclavian would be possible if the patient was able to lay flat but may end up with problems from the lesion on his left chest wall. Left IJ would also be related to some radiation and would have obtuse course. With this being the case the PIC line appears to be the best source. History and physical are reviewed and are otherwise unchanged.

  2. #2
    Default
    [QUOTE=AR2728;152591]This is a bit lengthy but necessary. Patient was scheduled for surgery however, surgery not carried out and physician wants to bill a level of E&M. I'm having a hard time pulling out components to bill and E&M or even the diagnosis to use. PLEASE HELP!---No mention of time spent and should note H&P from mentioned visit was comprehensive.

    The patient did present this morning and was cleared medically by Family doctor. Patient did come in this morning, and history and physical are reviewed, and are unchanged from his March 3rd note. The patient, however, was [re-]evaluated by anesthesia, and briefly by ENT. They did not feel that the patient could be put to sleep under general anesthesia because of concerns about the airway and general overall comorbidities. This statement is just giving some background, but it could also be considered a Chief Complaint - the CC being: the patient's airway and overall health condition, is too unstable to undergo anesthesia, and consequently, his surgery. You can't count the previous H&P in History, but it would go towards the Diagnosis Options portion of MDM. The doctor must record his own HPI and Exam in order for it to count (they have to be his own observations, in other words). I could give credit for Location under HPI, but only after some creative-re-arrangement of the note...(I moved the "exam" to where it would normally be)

    The patient did have an attempted procedure under just sedation previously and would not tolerate this. He became short of breath even head was elevated only about 30 degrees. Past Procedure History., And the 2nd sentence is HPI Associated Signs/Symptoms or Context - not both.

    The anesthetist did evaluate the patient, did not think he was a candidate for being put to sleep under general anesthesia. HPI Severity
    Apparently there were discussions with ENT who did not think that a surgical airway would even be possible if they were unable to get an airway while putting him to sleep. {MDM - consulting another MD}
    The patient cannot tolerate lying flat in order to have this put in. {HPI Context}

    Currently after nebulizer treatment his lungs are clear with increased expiratory phase, heart is regular. Exam - Respiratory, CV
    He does have the lesion on his left rib which is bony and hard. Exam - Musculoskeletal
    He also has a lesion on his left neck which is unchanged. Exam, Neck or Skin
    He has increased upper airway soft tissues. Exam - ENT
    Sclera anicteric. He does have the macular degeneration. Exam: Eyes
    His heart is regular. Exam, CV - not counted separately from the previous 'heart is regular' phrase.
    His abdomen is benign. Exam - Abdomen
    Looking at his periphery he does have some IV sites. Skin

    I did review this with the patient and his family. I also discussed this by phone with Dr. With this being the case it is the opinion of everybody that it would be best to try to place a PIC line in his antecubital and thread this centrally. This would negate any risks to nicking his lung which would cause pneumothorax and would have a high risk of being fatal in this gentleman. It would negate the risks of airway concerns and general anesthetic. All were in agreement. I did discuss this and will set up a time for the patient and have him treated with a PIC line.

    Patient was then set up and was having trouble breathing at 30 degrees but with sitting both upright was much better. Will consult PIC line service. CT and other films were evaluated and the patient in December did have a lesion on the third rib where he now has a much larger lesion. He also has radiation injury to his right neck and apersistent mass. Placement of a right neck is therefore not possible and is complicated by radiation injury. Placement of a right subclavian was also complicated by radiation. Left subclavian would be possible if the patient was able to lay flat but may end up with problems from the lesion on his left chest wall. Left IJ would also be related to some radiation and would have obtuse course. With this being the case the PIC line appears to be the best source. History and physical are reviewed and are otherwise unchanged.

    You should have enough elements to pull off a high-level E/M, but picking one may not be easy. You have high risk, high MDM, Comprehensive History (Including ROS and PFSH from previous encounter), so it's all in how much credit you can give in the Exam. Whatever you choose, it's probably going to need a modifier to indicate increased procedural services. Hope that's helpful in pointing you towards the answer...

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