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Code This!

Scenario Week of July 19, 2010:
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The setting is an outpatient hospital emergency room subject to the Outpatient Prospective Payment System (OPPS). A 67-year-old female presents to the emergency room following a minor car accident while the patient was driving home from her son’s house. The patient states she hit a side rail on the highway and that no other persons were injured. She complains of a headache caused by the force of the air bag deployment from the car steering wheel.

The emergency room physician, Physician X, performs a comprehensive history and physical evaluation, as well as an examination. Physician X determines the patient has only minor injuries and is not badly hurt. He prescribes medication for the headache and advises the patient to rest over the next few days. The patient is then released to go home.

Later the same day, the patient presents to the emergency room once again; this time the patient presents with complaints of chest pain and anxiety. A different emergency room physician, Physician Y, must review the patient medical records to gather information about the patient’s earlier visit. Physician Y must perform another comprehensive history and physical and evaluation to identify any cardiac problems. Physician Y admits the patient to observation status and orders an EKG. After evaluating the EKG and closely monitoring the patient in observation for five hours, Physician Y determines no additional physical problems and discharges the patient with a diagnosis of anxiety disorder.


Diagnosis 784.0 Headache 786.50 Chest pain, unspecified 300.00 Anxiety state, unspecified E815.0 Other motor vehicle collision with object on the highway

Procedure 99283 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate 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 presenting problem(s) are of moderate severity.

99283-27 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate 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 presenting problem(s) are of moderate severity.

93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report

G0378 x 5 Hospital observation service, per hour

Rationale ICD-9-CM code 784.0 describes the patient’s headache condition while code E815.0 best describes the automobile accident resulting in the first ER visit. ICD-9-CM code 786.50 describes the patient’s symptoms during the second ER visit caused by her diagnosis of 300.00, which accurately describes the patient condition, also during the second ER visit. The Official Coding guidelines state that it is acceptable to report signs and symptoms in addition to the established diagnosis as long as the sign/symptom is not integral to the diagnosis. Chest pain is not integral to the anxiety disorder.

As the patient presented to the emergency room twice, during two separate occasions in the same day, the billing of CPT code 99283 twice — once by itself and then again with modifier 27 Multiple Outpatient Hospital E/M Encounters on the Same Date, to signify the second ER visit — is appropriate.

CPT code 99283 is assigned for both encounters based on the specific criteria developed by the individual facility. It is important to note that these E/M codes are assigned based on the resources used and work done by the facility staff. .

The patient was admitted to observation status for a total of five hours. This supports the charge for five units of HCPCS code G0378.

This hospital employs a team of cardiologist to interpret the EKGs performed. Because these physicians are hospital employees (i.e., facility staff), it would be appropriate to report CPT code 93000, which identifies the global charge for an EKG, capturing both the professional and technical components.

 
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