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Code This!

Scenario Week of May 13, 2010:
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Case Study:

A 5-year-old girl is admitted to the observation department of the hospital following three days of abdominal pain, diarrhea, and vomiting. The abdominal pain is severe at times. She is lethargic and has decreased urinary output. She is unable to keep down clear liquids. She has a fever of 103. Review of systems was comprehensive. It included constitutional, neurological, ENT, eyes, cardiovascular, respiratory, gastrointestinal, endocrine, hematological, genitourinary, musculoskeletal, and integumentary. It was negative for any respiratory symptoms or rashes. A complete past, family, and social history was taken and is notable for the patient attending daycare and no history of chronic illnesses.

Physical exam: The child is lethargic but responds to verbal commands. Vital signs: heart rate 98; respiratory rate 25; temperature 102.5; blood pressure 90/63. Eyes: PERRLA. The skin shows decreased turgor and mucous membranes are dry. The neck is supple without adenopathy. Lungs are clear to auscultation with no rales, no wheezing. Heart is regular rate and rhythm, no murmurs. Abdomen is soft, nontender, with increased bowel sounds.

Plan: Rehydrate with intravenous fluids, monitor electrolytes, urine, and weight changes. Obtain a complete blood count (CBC) and electrolytes. Due to the patient’s diarrhea, a stool culture will be performed for evaluation of rotavirus. Abdominal CT was obtained and is negative. Acetaminophen will be used to treat the patient’s fever.

Diagnosis: Dehydration due to gastroenteritis

CPT Code 99218 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to “observation status” are of low severity.

Rationale Hospital observation service codes are used to report services provided to patients designated as under observation status in a hospital. Observation services may be provided in an observation unit or some other hospital unit. These codes include the initiation of the observation status, supervision of patient care including writing orders, and the performance of periodic reassessments. These codes are used only by the physician “admitting” the patient for observation. These codes are not determined by whether the patient is new or established. These codes are selected based upon the three key elements of history, exam, and medical decision making. The history elements: Chief complaint present, HPI was extended (4 or more elements), ROS was complete (10 or more systems), and PFSH was complete (3 of 3 elements) for a detailed level of history. The exam under the 1995 guidelines met the requirements for a detailed exam (2-7 organ systems with at least one more detail). The exam under the 1997 guidelines does not meet the requirements for a detailed exam (12 elements identified by a bullet in two or more areas/systems of the general multi-system exam or 2 elements from at least 6 systems). The medical decision making elements documented included: Number of diagnoses or management options was multiple with a new problem. Amount or complexity of data was low (ordering of radiology testing and lab testing). Table of risk was moderate (acute illness with systemic symptoms). The final level of decision making is moderate. The history level was detailed, exam level was detailed, and medical decision making was moderate. All three key component levels must be met or exceeded for an observation encounter. The levels of key elements meet those required for code 99218.

ICD-9-CM Codes 276.51 Dehydration 558.9 Other and unspecified noninfectious gastroenteritis and colitis 780.60 Fever, unspecified

Rationale Dehydration is characterized by excessive free water loss and plasma volume contraction disproportionate to the loss of sodium. Solutes become imbalanced resulting in hypernatremia (increased concentration of serum sodium) as an indicator for true dehydration. Blood volume can be replaced, but the plasma solutes must be correctly balanced as well. Gradual volume restoration is imperative to restore optimal fluid balance slowly.

Dehydration may follow bouts of diarrhea, vomiting, or profuse sweating. It is often a manifestation of the patient’s illness (e.g., gastroenteritis), and in such cases, the code for dehydration would not be sequenced first. However, if the patient’s dehydration becomes significant enough to warrant separate treatment for rehydration, the dehydration code would be sequenced first.

In addition, code 780.60 is assigned because the documentation clearly states that the patient presented with fever.

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