Medical Billing Forum

Coding => Coding => Topic started by: ZiCoding on September 04, 2014, 03:17:47 AM

Title: E/M Coding Struggle
Post by: ZiCoding on September 04, 2014, 03:17:47 AM
Can someone please answer this question correctly for me?

I am looking for the:
Principal Dx:
Secondary Dx:

Chief Complaint: Shortness of breath

History of Present Illness:  The patient is a 55-year-old Caucasian male with a past medical history significant for psychiatric issues, anxiety and emphysema.  He presents to the ED with a chief complaint of shortness of breath.  He states he has had shortness of breath since 1976 but has acutely gotten worse as of yesterday. The patient states that he has a chronic cough but has not developed any sputum production. The patient stated he had fever last night but took Tylenol and the fevers has since resolved. In addition, the patient also complains of right-sided rib pain located over the middle portion of the eighth rib. He also endorses substernal chest pain that has occurred for the past five years on and off. The patient was experiencing chest pain earlier in the day, however, is not currently experiencing any chest pain.  The patient is very intoxicated on presentation to the ED and as a result, questions related to his history of present illness and review of systems were very difficult to ascertain as the patient was confused, easily agitated with extensive questioning, and was inappropriate in many of his answers to the questions presented. 

Past Medical History:
1.  Psychiatric issues, not otherwise specified.
2.  Anxiety.
3.  COPD, emphysema

Side pain, chest pain per HPI. The patient denies abdominal pain, nausea, vomiting diarrhea or constipation. All systems reviewed and are negative unless otherwise stated.

Social History: The patient endorses smoking cigarettes and drinking alcohol daily. The patient denies illicit drug use.

Allergies: No known drug allergies

Vital Signs: Blood pressure 131/94, pulse of 126, respiratory rate of 20, satting 95% on room air with a temperature of 96.9
General: The patient appears intoxicated. He is easily agitated and confused. He is a well-developed, thin Caucasian gentleman that is also showing signs of mental instability as he has expressed paranoid concerns and severe depression.
HEENT: Normocephalic, atraumatic. Pupilís equal, round, reactive to light.
Oropharynx: Monerythemic, no discharge noted.
Neck: Supple. No lymphadenopathy, trachea midline
Cardiovascular: Tachycardia rate, regular rhythm. No murmurs appreciated.
Respiratory: Clear to auscultation bilaterally
Abdomen: Thin, nondistended, nontender to palpation, hyperactive bowel sounds appreciated.
Extremities: He has 2+ pulses throughout. No edema noted.
Neurological: The patient is able to move all extremities with equal strength bilaterally. Sensory exam grossly intact.
Psychiatric: The patient appears to express paranoid delusions and is depressed as he has frequent crying outbursts and endorses a depressed mood. The patient denies suicidal ideations or homicidal ideations.

Emergency Department Course: 

As a means to workup the patientís complaint of shortness of breath and chest pain, an EKG was obtained. It showed a tachycardic rate of 113 with a sinus rhythm.  Access was indeterminate, with normal intervals. There was a predominate P wave present consistent with right atrial enlargement. There was no ST wave changes that were concerning for ischemia. Laboratory data that was obtained included a CBC which did not show an elevation in the patientís white count and a hemoglobin of 16.1 with a hematocrit of 46.8. The patient had a normal differential.

To control the patientís pain, Dilaudid was given.  For patientís tachycardia 1 liter IV fluid normal saline bolus was given.

Patient was taken to Radiology for a chest x-ray that showed hyperinflated lung fields, but were negative for acute disease. This rolled out the concern for possible pneumonia or pneumothorax for patientís shortness of breath and chest pain.

Because there remained a concern for a pulmonary embolus causing the patientís symptoms, a CT Pulmonary Angiogram was also performed. The results showed no evidence of pulmonary embolism, however, there was a questionable right lateral eighth rib fracture noted. There was also airspace opacity noted in the posterior right lower lobe which is nonspecific and may be infectious or inflammatory in nature.

Disposition and condition: Patient to be discharged home in stable condition.

Clinical Impression:
1.  Chest Pain
2.  Shortness of breath, not otherwise specified
3.  Possible subacute rib fracture   
4.  Intoxication.

1.  The patientís right-sided pain may be secondary to a subacute rib fracture. This may be a contributing factor as well as the patientís shortness of breath. There is no medical intervention that can be done for this. The patient was instructed to take ibuprofen and Tylenol for his rib pain. No narcotics were prescribed to this patient.
2.  The patient was instructed to return to the ED if he experienced worsening chest pain, shortness of breath, diaphoretic episodes or fever. He was also instructed to return if he developed nausea, vomiting, change in his cough or sputum production or if he started having suicidal ideations.  The patient voiced understanding and agreed with the plan.

Title: Re: E/M Coding Struggle
Post by: kristin on September 04, 2014, 08:21:28 PM
What is this for?
Title: Re: E/M Coding Struggle
Post by: Michele on September 07, 2014, 07:50:24 PM
This appears to be a 'homework' question.  We are more than happy to help others in this field but simply posting a homework question and asking others to answer it is really not ethical.  You don't learn anything by having someone else simply answer it.  If you had posted your response/answer and asked for verification or input on if you were on track that would be different. 
Title: Re: E/M Coding Struggle
Post by: kristin on September 08, 2014, 06:42:20 PM
Michele, this is exactly why I asked the question I did...seemed like homework to me too!
Title: Re: E/M Coding Struggle
Post by: Michele on September 09, 2014, 07:37:22 AM
Michele, this is exactly why I asked the question I did...seemed like homework to me too!

I know but I figured I'd spell it out.   ;)
Title: Re: E/M Coding Struggle
Post by: PMRNC on September 09, 2014, 09:05:27 AM
If it was not a homework question, I'd like to add that even though there was no PHI .. I found it a little unethical to post someone's medical record,  on a public forum.   I don't like answering coding questions for this reason.