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Code This!

Scenario Week of September 21, 2012:
View Current Scenario

Assign the appropriate ICD-9-CM diagnosis and procedure codes as well as CPT for the following outpatient scenario:

Scenario: A 47-year-old male patient presents to the emergency department with a 5-hour history of severe nausea, vomiting, abdominal cramping, and diarrhea beginning several hours after eating at a fast-food restaurant. His diagnosis is gastroenteritis due to food poisoning, presumed to be bacterial.

Patient history: Describes himself as usually very healthy. No history of gastritis or colitis or other gastrointestinal conditions. Usual childhood diseases. Surgery at age 16 for an accessory navicular of his right foot.

Social history: Nonsmoker; occasional social use of ETOH

ROS is negative for other gastrointestinal indications or cardiovascular indications.

Patient is a WD/WN male patient in obvious distress. VS-BP 128/78, P 92, R 22 T 99.7. He appears quite ill and pale, diaphoretic, with obvious facial petechiae. His lungs are clear. Heart is normal sinus rhythm, no murmurs. His abdomen is normal except for epigastric tenderness and hyperactive bowel sounds. There are no masses, spleen and liver are WNL. No hernias are identified.

An intravenous infusion of 0.9% NaCl was started. He was given Phenergan 25mg IM. CBC and blood chemistries were within normal limits. His symptoms began to abate and he stated he felt much better. He was discharged home with his wife. He was encouraged to drink fluids and gradually advance his diet as tolerated. He was given a prescription for Lomotil and told to follow-up with his primary care physician as necessary, or to return to the emergency department if symptoms worsen.

Code This! Assign the correct CPT and ICD-9-CM diagnosis and procedure codes.

ICD-9-CM Code: 005.9 Unspecified food poisoning

CPT Code: 99282 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 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 presenting problem(s) are of low to moderate severity.

Rationale: The documentation requirements for code 99282 include the key components of an expanded problem focused history, an expanded problem focused examination, and medical decision making of low complexity, all of which must meet or exceed the specific level of service. For this level of care, problems are considered to be of low to moderate severity.

In this scenario, the criteria for an expanded problem focused history are met as they include the patient’s chief complaint, a history of the current illness that includes more than four elements, and a history of the patient’s past illnesses and social activities. The ROS is specific for the patient’s gastrointestinal symptomatology and is problem pertinent. The examination for this patient is also problem-focused, centered on the gastrointestinal, cardiovascular, and respiratory systems and meeting seven of the bulleted elements in a general multisystem examination. The medical decision making for this scenario involves only a limited number of diagnoses and treatment options, and the patient’s risk for this acute, but self-limited illness in an otherwise healthy individual is low. Overall, this represents low complexity medical decision making. This visit meets the criteria for code 99282.

When you look in the ICD-9-CM index under the main term “Gastroenteritis” and the subterm “due to food poisoning” a note indicates “See also Poisoning, food” which indicates the coder will need to go to the term referenced by this note for the correct code assignment. Under the main term “Poisoning, food” which lists a number of specific types of food poisoning, such as that caused by specific organisms and types of food. In this scenario, the organism causing the food poisoning is not documented, and in the absence of any more specific information, code 005.9 would be assigned.

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