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Code This!

Scenario Week of June 18, 2014:
View Current Scenario

Provide the appropriate ICD-9-CM diagnosis code(s) and CPT code(s) for the following scenario.

A 35 year-old-female presents to the emergency department accompanied by her husband with complaints of dyspnea, mid-line chest pain, and rib pain on the left side for the past four days. She appears to be in moderate distress.

History of present illness: Patient was seen in the office two days ago by her primary care physician for shortness of breath and moderate pain of the chest and ribs. She was treated for an exacerbation of longstanding asthma and prescribed nonsteroidal antiinflammatory medication for suspected costochondritis. Although her asthma improved, the pain continued and worsened with activity, deep inspiration, and lying supine. She has a history of asthma, under good control until this most recent exacerbation. Recent travel includes a business-related trip to Japan one month prior to developing symptoms.

Review of systems: She denies fever, chills, and abdominal symptoms. She denies leg pain, cramping, or swelling. Chest pain decreases when leaning forward. Denies hemoptysis. Denies heart palpitations.

Past medical history: Extrinsic asthma since childhood under good control with Aerobid twice daily and Albuterol PRN. Had an ORIF of the tibia at age 15 for a fracture due to a sports-related accident.

Social history: She lives with her husband. She works as a marketer for a large international corporation. Denies tobacco, alcohol, or illicit drug use.

Family history: Both parents alive and well. Patient has two sisters, both alive and well.

Medications: Yasmin 1 tab po daily, Albuterol inhaler PRN, Aerobid inhalant 500 mcg bid

Allergies: Penicillin

Physical exam: Well developed, well-nourished female patient in moderate distress with shortness of breath and chest pain. She is mildly diaphoretic. Circumoral cyanosis evident. Appears to be quite anxious.

  • Vital signs: Afebrile, BP 104/58, Pulse at rest 105. Respirations: 38. Sa02 99%
  • General: Alert and oriented X3, moderate distress
  • HEENT: Normal
  • Neck: Supple, no lymphadenopathy, thyroid WNL
  • Respiratory: Splinting, shallow breaths, diminished breath sounds in the left lower lobe, with no wheezes or rhonchi. No pleural friction rub. No cough.
  • Cardio: Regular rhythm, slightly tachycardic, no murmur, rub, or gallop.
  • Abdomen: No CVA tenderness, no bruits, nontender, nondistended, active bowel sounds.
  • Musculoskeletal: Guarding of the left abdominal musculature and spasm of the left quadratus lumborum and intercostal muscles of ribs 8-12. Anterior and posterior tenderness of the left lower rib cage.
  • Derm: No lesions, WNL.
  • Extremities: Dorsal pedal and posterior tibial pulses 2+. Lower extremities without edema, tenderness, or erythema. Homan's negative, Thompson's negative.

Patient was started on supplemental oxygen and an IV of normal saline. She was given a nebulizer treatment with Albuterol for her asthma.

The following diagnostic tests were performed:

  • CMP: normal
  • CRP: 10
  • Sed Rate: 62
  • Hemoglobin/Hematocrit: normal
  • WBC: 11.8
  • D-Dimer: 3.0

Chest x-ray: Blunting of the left costophrenic angle suggestive of minimal atelectasis or early infiltrate of the left lung base with small adjacent pleural effusion. No bony abnormalities.

EKG: WNL

CT angiography: Pulmonary emboli noted within the segmental and interlobar arteries to the left lower lobe. Consolidated change of the left lung base and the pleural effusions noted. The consolidation could be ischemic change from the pulmonary emboli or superimposed pneumonia.

Bilateral lower extremity ultrasound: Negative for deep vein thrombosis of lower extremities.

Impression: Pulmonary embolism probably secondary to use of oral contraceptives and/or recent flight to Japan. History of asthma with acute exacerbation.

Plan: Admit patient for anticoagulation therapy. Continue asthma medications. Start Albuterol nebulizer treatments.

Please assign the correct ICD-9-CM and CPT codes for the procedure above.


ANSWERS

ICD-9-CM Codes and Rationale
415.19 Pulmonary embolism and infarction, other
493.02 Extrinsic asthma, with (acute) exacerbation

This patient has been diagnosed with a pulmonary embolism (PE), a blood clot most often originating in the leg veins which can break free and travel to other body organs including the lungs. The PE can block the pulmonary arteries and diminish the flow of blood to the lungs. Anticoagulants are provided to dissolve the clot and to keep new ones from forming. Birth control pills and long flights are both known risk factors for the development of a PE. However, in this scenario, neither condition has been implicated as the cause of the PE, so no additional codes related to birth control pills or air travel are necessary.

The patient is noted to have chronic extrinsic asthma since childhood with a current acute exacerbation of this condition; therefore, the fifth digit subclassification of “2” is appended to code 493.0.

CPT Code and Rationale
99284 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components:
A detailed history,
A detailed examination; and
Medical decision making of moderate complexity

For this patient, code 99284 is selected based on the documented components of the evaluation and management service. The chief complaint is documented as well as an extended history of present illness; review of systems; and a complete past, family, and social history. These elements comprise a detailed history. The examination includes more than the required 12 elements of a detailed examination under the 1997 guidelines and the extended examination of the affected body area and other related organ systems or body areas required by the 1995 guidelines. Medical decision making appears to be of high complexity based on the table of risk. Because three of the key elements must be met to qualify for a specific level, and the history and examination are both classified as “moderate,” code 99284 is chosen.

 
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