by Associated PressSaturday, November 30th 2019AA

CDC officials say it’s not too late to get vaccinated. (MGN Online)

JACKSON, Miss. (AP) — The flu season is off and running in the Deep South.

The most recent weekly flu report from the Centers for Disease Control and Prevention finds high levels of flu-like illness in Alabama, Arkansas, Georgia, Nevada, South Carolina and Texas. The highest level in that report for the week ended Nov. 16 was in Mississippi.

Doctors in the Magnolia State say they’re already seeing lots of patients. Dr. Darren Scoggin of Children’s Medical Group in Jackson tells WLBT-TV that travel and family gatherings can help contribute to the flu’s spread.

CDC officials say it’s not too late to get vaccinated. They say the flu vaccine is the best way to prevent flu and its complications.

So far in the 2019-2020 flu season, CDC has reported four flu-associated deaths among children.

Outpatient observation

Outpatient observation services are covered only when provided by order of a physician or another individual authorized by state licensure and hospital staff bylaws to admit patients to the hospital or to order outpatient tests.

Do not order observation services for a future elective surgery or outpatient surgery cases. Neither pre-operative nor post-operative services meet the definition of observation care.

Observation services must be patient specific and not part of the facility’s standard operating procedures. If observation is required after an outpatient surgical procedure and the patient meets criteria for observation monitoring after the standard surgical recovery period, you can place the patient in outpatient observation; however, the observation care will be bundled into payment for the surgical procedure.

Observation services are not considered medically necessary when the patient’s current medical condition does not warrant observation, or when there is not an expectation of significant deterioration in the patient’s medical condition in the near future.

Observation status

Outpatient; released when the physician determines observation is no longer medically necessary

Physician’s order is required

Lack of documentation can lead to claim errors and payment retractions

An order simply documented as “admit” will be treated as an inpatient admission. A clearly worded order such as “inpatient admission” or “place patient in outpatient observation” will ensure appropriate patient care and prevent hospital billing errors.

Note: It is imperative that there is a continued focus on lowering the Comprehensive Error Rate Testing rate and facility involvement is a key component to this goal.

Outpatient Observation Notice

All patients receiving services in hospitals and clinical access hospitals (CAHs) must receive a Medicare Outpatient Observation Notice (MOON) no later than 36 hours after observation services as an outpatient begin.

The MOON informs patients, who receive observation services for more than 24 hours, of the following:

They are outpatients receiving observation services and not inpatients

Reasons for such status

Hospitals and CAHs may deliver the MOON to a patient receiving observation services as an outpatient before the patient has received more than 24 hours of observation services but no later than 36 hours after observation services begin.

Observation Hours

Not expected to exceed 48 hours in duration

Greater than 48 hours in duration are seen as rare and exceptional cases

Cover up to 72 hours if medically necessary

Observation services rendered beyond 72 hours is considered medically unlikely and will be denied

Follow the appeals process to have observation services exceeding 72 hours considered for payment

Observation Billing Requirements

Observation services are outpatient services.

Type of bill 13X or 85X

Revenue code 0762

HCPCS code

G0378: Hospital observation service, per hour. Report units of hours spent in observation (rounded to the nearest hour).

G0379: Direct admission of patient for hospital observation care.

Report all services rendered while the patient is in observation with the appropriate revenue codes, HCPCS / CPT codes, and diagnosis codes

Observation services should not be billed along with diagnostic or therapeutic services for which active monitoring is a part of the procedure. In situations where such a procedure interrupts observation services, hospitals may determine the most appropriate way to account for this time.

Example

A hospital may record for each period of observation services, the beginning and ending times, during the hospital outpatient encounter and add the length of time for the periods of observation together to reach the total number of units reported on the claim for the hourly observation services HCPCS code G0378 (Hospital observation service, per hour). A hospital may also deduct the average length of time of the interrupting procedure, from the total duration of time that the patient receives observation services.

Observation Spanning More Than One Calendar Day

Observation may span multiple calendar dates.

When outpatient observation services span more than 1 calendar day:

The total accumulation of observation time for the entire period of observation must be included on a single line

The date of service would be the date observation care began

In the Observation claim example below, notice that observation care spans 3 calendar days.

The statement from and through dates will reflect the entire outpatient episode of care, in this instance 01/01/17 through 01/03/17.

The patient is placed in observation from 8:00PM on 01/01/17 and remained until discharge at 12:00PM on 01/03/17 for a total of 40 hours of observation time.

Report one line item with revenue code 0762, HCPCS code G0378, line item date of service 01/01/17 and 40 units.

The total accumulation of observation time is included on one line with the date observation care began.

Reminders

Observation services are provided on an outpatient basis

Should be billed according to observation billing guidelines

All hours of observation should be submitted on a single line

The date of service being the date the order for observation was written

Orders for observation services are not considered to be valid inpatient admission levels of care orders.

When billing observation services, we expect the charges associated with those services to be billed as outpatient level of care services.

Observation to Inpatient Status

Observation ends when all clinical or medical interventions have been completed, including follow-up care furnished by hospital staff and physicians that may take place after a physician has ordered the patient be discharged home or admitted as an inpatient.

If the patient is admitted as an inpatient after observation, an order to admit is required.

Additionally, if the patient is discharged from observation and subsequently admitted as an inpatient, all services provided to the patient while in observation are included on the inpatient claim.

Since observation is considered an outpatient hospital service performed within 3 days of an inpatient admission, the services follow the 3-day/1-day payment window.

References

CMS Internet Only Manual (IOM) Publication 100-04, Claims Processing Manual, Chapter 3, Section 40.3

CMS IOM Publication 100-04, Claims Processing Manual, Chapter 4, Section 290

Medicare Learning Network (MLN) Matters, MM9935-Medicare Outpatient Observation Notice (MOON) Instructions

Observation Services FAQs

Understanding Inpatient vs. Observation

Basics of Sepsis ICD-10 coding

When we talk about ICD 10 codes, we are talking about specificity in each aspect. The ICD 10 codes are arranged in such a way that coders should be able to code the perfect and specific diagnosis code.  

Now, ICD 10 codes cannot be used as single code like CPT codes to represent a word procedure. ICD 10 has increased in number compared to ICD 9 because of using multiple diagnosis codes when required. Yes, their are many scenarios where we have to use 2 or more ICD 10 codes to give more specific information about diagnosis codes. 

For example, pregnancy complication ‘O’ codes require a Z3A category codes for specific weeks of gestation. Similarly, their are many combination codes for hypertension, diabetes which require multiple codes. But, today we will learn about coding spesis codes. Medical coders find it very difficult to code sepsis because of it different variations. Sepsis, septicemia,  SIRS, Severe sepsis and sepstic shock are the main terms used in diagnosis coding in medical coding.

Sepsis

Sepsis is a Systemic disease associated with the presence and persistence of streptococcal pathogenic microorganisms and their toxins in the blood. Sepsis is also called Septicemia.

ICD 10 codes for Sepsis

Generalized sepsis codes should be reported from A40 & A41 series ICD 10 codes. When sepsis with specified organism is documented  code the specific code, if unspecified report A41.9 ICD 10 code.

A41.9  Sepsis, unspecified organism

SIRS with or without infectious origin

Systemic inflammatory response syndrome (SIRS) generally refers to the systemic response to infection, trauma/burns, or other insult (such as cancer), with symptoms including fever, tachycardia, tachypnea, and leukocytosis. SIRS are of non-infectious origin. Do not get confuse with severe sepsis because sepsis always means an infection, while SIRS can be with or without infection.

SIRS with infectious origin should be coded with severe sepsis as per ICD 10 coding guidelines.

Sever Sepsis Coding Guidelines

Severe sepsis is more harmful than sepsis or viral sepsis because it is associated with an acute or mutiple organ dysfunction. But, while coding severe sepsis the documentation must support that acute organ dyfunction is related to sepsis. If the acute organ dysfucntion is not relation to sepsis than we should not report the severe sepsis code, we will only code the normal sepsis ICD 10 code.

Severe sepsis requires two additional codes along with severe sepsis ICD 10 code R65.20-R65.21. Two coding notes will be given above Sever sepsis ICD 10 code. Severe severe can also be called as:

• Infection with associated acute organ dysfunction                                                                                         
• Sepsis with acute organ dysfunction                                                                                                                   
• Sepsis with multiple organ dysfunction                                                                                                           
• Systemic inflammatory response syndrome due to infectious process with acute organ dysfunction

First ICD 10 code will be from below list.

Code first underlying infection, such as:

infection following a procedure (T81.4-)

infections following infusion, transfusion and therapeutic injection (T80.2-)

puerperal sepsis (O85)

sepsis following complete or unspecified spontaneous abortion (O03.87)

sepsis following ectopic and molar pregnancy (O08.82)

sepsis following incomplete spontaneous abortion (O03.37)

sepsis following (induced) termination of pregnancy (O04.87)

sepsis NOS (A41.9)

The “code first” note means code first, if present. The code first instruction should be followed only when the underlying conditions  are present or documented, if not it is not applicable.  This instructional note is intended for conditions that have both an underlying etiology and manifestation, and indicates the proper sequencing order: etiology first, followed by the manifestation.

After coding the infection, the coders have to code a severe sepsis ICD 10 code R65.20-R65.21 followed by the acute organ dysfunction code from below list.

R65.20 Severe sepsis without septic shock

R65.21  Severe sepsis with septic shock

Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction.

Use additional code to identify specific acute organ dysfunction, such as:

acute kidney failure (N17.-)

acute respiratory failure (J96.0-)

critical illness myopathy (G72.81)

critical illness polyneuropathy (G62.81)

disseminated encephalopathy (metabolic) (septic) (G93.41)

hepatic failure (K72.0-)

The above list of organ failure will specify the type of organ failure occured due to sepsis.

Sepsis due to device, implant or graft

Other related Sepsis ICD 10 codes

The ICD codes for sepsis occured due to presence of a device, implant or graft should be reported with T85.79 series codes.

T85.79  infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts

Sepsis can occur following a surgery procedure, such postprocedural infection have to be reported with ICD 10 T81.4 series codes.

T81.4  Infection following a procedure

Wound abscess following a procedure

Sepsis complicated pregnancy , Puerperium, childbirth & obortion

Coding for sepsis in pregnancy period requires multiple codes. The O code will be primary for coding pregnancy complication due to sepsis followed by the specified sepsis ICD 10 codes.

For Puerperal sepsis , assign O85 as primary code followed by the causal organism code from category B95-B96, Bacterial infections in conditions classified elsewhere. Do not use A40 or A41 series codes along with puerperal sepsis. In required, use severe sepsis (R65.2-) codes and any associated acute organ dysfunction.

Urosepsis

The term “urosepsis” is a nonspecific term and should not be considered synonymous with sepsis.

In Short all the Sespis related ICD 10 codes

Only Sepsis: A40 & A41 series codes

SIRS (Non-infectious) : R65.10 & R65.11 (followed by a acute organ dysfunction code)

Severe Sepsis or SIRS with Infection: R65.20 & R65.21 (followed by a acute organ dysfunction code)

ROCKVILLE, Md. (CBSNewYork/CNN) – A Maryland pharmaceutical company claims they may have created a potential cure for HIV.

American Gene Technologies announced it filed a 1,000-page application with the FDA on Wednesday as scientists there believe they have created a gene therapy unlike any other.

“We are doing this with a purpose with improving people’s living, relieving suffering and increasing their lifespan,” Irene Tennant said, via CNN.

AGT, announced the submission of an investigational new drug application for the company’s lead HIV program called AGT 103-T.

The single-dose drug has a simple purpose, to eradicate HIV once and for all. AGT said they are hoping to hear from the FDA before the end of the year.

If their application is approved, phase one clinical trials could begin in January.

From the time ICD 10 codes have been implemented, coders are facing lot of issues with new diagnosis codes. Injury codes in ICD 10 are still creating problems for coders. For non-traumatic or pathological fractures, we have discussed previously. But for traumatic fracture coding, medical coders are still having lot of confusion. The initial, subsequent and sequela encounters of injuries codes have made coding little complicated. But, today I will try to clear your doubt in this article about coding fractures and the different types of fractures used in medical coding.

Traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) for each encounter where the patient is receiving active treatment for the fracture. The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

When to use Subsequent encounter codes

But, when should be the subsequent encounters be coded in injury coding. When the patient has completed active treatment of the fracture and is receiving routine care during the healing or recovery phase, subsequent encounters are coded using the appropriate 7th character for subsequent care of fractures. Also the care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes. Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N) or subsequent care with malunion (P, Q, R).

Difference between an Open and Closed Fracture

Medical coders are mostly confused with coding closed and open fracture or the fracture is traumatic or pathological. So, always remember a fracture not indicated as open or closed should be coded to “closed.” If you are not aware of Open and closed fracture definition, just read the below description.

Closed or simple fracture—In this type of fracture, the bone is broken, but the skin is not lacerated.

Open or compound fracture— In open fracture, the skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound.

The steps of the coder is to find out whether the fracture is displaced or nondisplaced along with the site of fracture. A fracture not indicated as “displaced” or “not displaced” should be coded to displaced. Also, do remember for fracture in upper or lower extremity should be coded with specific laterality (RT, LT, Bilateral) in ICD 10 coding. There are many different types of fracture you may come across while coding injury reports. Below is a list of common types of fracture in detail found in ICD 10 CM coding.

Burst: Compression of vertebral body due to a fracture

Comminuted: Fracture has broken bones into several small pieces

Depressed: Fracture is a piece of bone that is depressed, more common in the skull

Elevated: Fracture is a piece of bone that is elevated, more common in the skull

Fissure: Incomplete fracture of the outer portion of a bone that is nondisplaced

Greenstick: Incomplete fracture with bending of the bone, more common in children

Impacted: The ends of the fractured bone are pushed into each other

Linear: Fracture that runs parallel along the length of the bone

Missile: Open fracture caused by an outside force with a projectile

Puncture: Open fracture that perforates the skin

Salter-Harris (I-IV): Fractures through the growth plate of a bone in children

Spiral: Fracture due to a twisting force that results in a spiral break along the bone

Torus: Similar to a greenstick fracture with buckling on one side of the break

Wedge : Compression fracture that occurs in the lateral or anterior part of the thoracic spine

Complications during Healing phase of Fracture

Once the fracture is under the treatment phase or healing phase, there may be few complications with fracture. There are three common complication which you can see during the healing phase of fracture, delayed union, Nonunion and Malunion. Below is the exact definition of these complications.

Delayed union—a delay in normal fracture healing; not necessarily a pathological process

Nonunion—failure of healing of a fracture or osteotomy; with continued motion through a nonunion, a pseudarthrosis will form

Malunion—healing of a fracture in an unacceptable position

Every year AMA (American Medical Assocaition) releases new updates for Current Procedural Terminology (CPT) codes. For this year 2020, again their will some new CPT codes, some codes will be deleted and some CPT codes will be revised.

Their are total 394 codes have been changed of which 248 are new cpt codes, 75 codes are revised and 71 codes are deleted.

The new changes in CPT codes for 202 will be effective from 1st January 2020.

The most considerable changes have been made in the Medicine section, with the addition of 23 new codes for reporting long term electroencephalographic (EEG) monitoring services to monitor the electrical activity of the brain. These services are critical for monitoring patients with epilepsy.  Additionally, many new codes have been added and revised in the Surgery and Pathology & Laboratory sections of the CPT code set.

Following are highlights of the new code(s) additions pertaining to the main sections in the CPT code set:

Evaluation and Management:

• Three new codes (99421-99423) and new guidelines have been established for reporting online digital evaluation and management (E/M) services (e-visits).
• Two new codes (99473-99474) have been added for reporting self-measured home blood pressure monitoring using a validated device.
• A new add-on code 99458 has been established to report each additional 20 minutes of remote physiologic monitoring treatment management services.

Surgery:

• New guidelines and five new grafting codes (15769, 15771-15774) have been added in the Dermatology subsection for reporting grafting of autologous soft tissue harvested by excision or autologous fat harvested by liposuction.
• In the Musculoskeletal subsection new guidelines and six new codes (20700-20705) have been added to report manual preparation and insertion of drug delivery devices and removal of drug delivery devices. In addition, two new codes (20560-20561) have been added to report needle insertions in muscles without injection(s) and three new codes (21601-21603) have been added to report excision of chest wall tumor.
• In the Cardiovascular subsection four new codes (33016-33019) along with new guidelines have been added to describe pericardiocentesis and pericardial drainage with insertion of indwelling catheter. Additionally, two new codes (33858-33859) and new guidelines have been added to describe ascending aortic graft, a new code 33871 has been added to report transverse aortic arch graft, two new codes (34717,34718) were added to report endovascular repair of the iliac artery and two new codes (35702-35703) have been added to report artery exploration in upper or lower extremities.
• In the Digestive subsection a new code 46948 was added to describe internal hemorrhoidectomy by dearterialization and two new codes (49013,49014) have been established to report preperitoneal pelvic packing and re-exploration with removal of preperitoneal pelvic packing.
• In the Nervous subsection two new codes (62328-62329) have been added to describe spinal puncture with fluoroscopic or CT guidance. In addition, four new codes (64451-64625) along with new guidelines have been added to describe injection of anesthetic agent and/or steroids into the somatic nervous system.
• In the Eye and Ocular Adnexa subsection two new codes (66987-66988) were added to describe extracapsular cataract removal.

Radiology:

• A new code 74221 has been established for a double-contrast radiologic examination of the esophagus.
• A new add-on code 74248 has been added for radiologic small intestine follow-through study.
• Five new codes (78429-78433) have been established to report myocardial imaging positron emission tomography (PET) studies with computed tomography (CT) transmission scan, as well as to report studies at rest and/or during stress. Add-on code 78434 has also been added to report absolute quantification of myocardial blood flow (AQMBF) previously reported with Category III code
• Three new codes (78830-78832) have been added to report nuclear medicine tomographic SPECT studies for radiopharmaceutical localization of tumor. Add-on code 78835 has been established to report radiopharmaceutical quantification measurement(s).

Pathology and Laboratory:

• Six new therapeutic drug assay codes have been established to describe the following: Adalimumab (80145), Infliximab (80230), Lacosamide (80235), Posaconazole (80187), Vedolizumab (80280) and Voriconazole (80285).
• Four new Tier I molecular pathology codes have been added:(81277) to describe cytogenomic neoplasia microarray analysis for chromosomal abnormalities and codes (81307-81309) to describe cancer gene analysis.
• Three new multianalyte assay codes with algorithmic analyses have been added: (81522) to describe oncology (breast), mRNA gene expression profiling of 12 genes; (81542) oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes; and (81552) oncology (uveal melanoma), mRNA gene expression profiling of 15 genes.
• A new microbiology code 87563 has been added to report for mycoplasma genitalium, amplified probe technique.
• Seventy-five new codes (0062U-0138U) have been established to report proprietary clinical laboratory analyses (PLA).

Medicine:

• Two new vaccine codes have been established: 90694 for reporting Influenza virus vaccine for intramuscular use, quadrivalent (allV4), inactivated, adjuvanted, preservative free, 0.5 mL dosage, and code 90619 for reporting meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier for intramuscular use.
• Two new codes (90912-90913) have been added for reporting biofeedback training, perineal muscles, including EMG and/or manometry when performed.
• Two new codes (92201-92202) have been added for reporting extended ophthalmoscopy.
• A new code 92549 has been established for reporting computerized dynamic posturography sensory organization test with motor control (MCT) and adaptation test (ADT).
• A new add-on code 93356 has been added to report myocardial strain imaging using speckle tracking.
• Two new codes (93985-93986) and new guidelines have been added to report duplex scan of arterial inflow and venous outflow for preoperative vessel assessment prior to creation of hemodialysis access.
• Twenty-three new codes (95700-95726) and new guidelines have been established for reporting electroencephalographic (EEG) monitoring services.
• New guidelines and nine new codes (96156-96171) have been added to report health behavior assessment and intervention.
• Two new codes (97129-97130) have been added to report therapeutic intervention procedures that focus on cognitive function.
• New guidelines and three new codes (98970-98972) have been added to report online digital evaluation and management (E/M) services by qualified nonphysician health care professionals.

In addition to the main section changes, five new Category II codes have been established for performance measurement and fifty-one new Category III temporary codes have been established to track emerging technology services and procedures. 

It is always good practice to prepare your providers, coders and billing staff for the upcoming changes and make certain they receive adequate training. Thinking about infrastructure, your office systems and any administrative forms should be updated to accommodate the changes in the code set. It is important to have all this preparation completed prior to January 1. For a complete list of the changes and official CPT guidelines, refer to the 2020 CPT code book and Appendix B for the summary of additions, deletions and revisions. Stay tuned for additional blogs regarding specific section changes.

Chief Complaint & History of Present Illness :  

18 year old female presents with pregnancy issues at 9 weeks.Patient reports having stomach pain last night that felt like kicking, but she knew it was too early.She states that her stomach felt heavy, and she woke up with the same pain this morning along with vaginal spotting.Standing and walking aggravates her pain.Patient is G2P1.

 Past Medical History :  

PMH: None

Primary MD: MCC

Historical Diagnoses (Full Problem List)

AP – Abdominal pain (2016), Ovarian cyst rupture (2016)

Allergies

Bupropion(hives)

Home Medications

Analpram-HC Cream, 1 application rectally 4 times per day PRN hemorrhoids

Colace, 250 milligram orally every day

Epsom Salt Solution, 1 application topically 3 times per day

Motrin, 600 milligram orally every 6 hours PRN pain

prenatal ukn type,

Tucks 50 % Medicated Pads, 1 pad topically every day PRN skin irritation

Immunizations

Tdap – 115 (2017)

Social History

Unremarkable

Tobacco Use

None Reported : TOBACCO HISTORY Last Documented By: AMANDA TARGETT, RN on 01/20/19:31

Alcohol Use

None Reported : ALCOHOL HISTORY Last Documented By: KRISTEN HOFFMAN, RN on 12/01/18:53

Recreational Drug Use

None Reported : RECREATIONAL DRUG HISTORY Last Documented By: IAN R. CANTOR, RN on 04/07/21:04

Review Of Systems

ROS: No fever or chills

No visual changes

No sore throat or earache

No chest pain or palpitations

No shortness of breath or cough

No pain with urination or hematuria

No abdominal pain nausea vomiting or diarrhea

No skin rashes

No focal weakness or numbness

No bruising or ecchymosis

ROS: Rest of the review of systems is negative except as listed in the HPI

Vital Signs

Most Recent Set of Vitals:

BP: 110/64 09/30/2019 11:29

Pulse: 94 09/30/2019 11:29

Temp: 36.7 C 09/30/2019 11:29

Resp: 16 09/30/2019 11:29

02 Sat: 99%(Room Air) 09/30/2019 11:29

Calculated BMI: 27.5 09/30/2019 11:29

Physical Exam

General: Alert and oriented x3.Well developed, well nourished, well appearing.Anxious resting comfortably in bed.

Non icteric.

Hematologic: no bruising or ecchymosis.

Skin: Warm and dry, no rashes or lesions.

HENT: Normocephalic, atraumatic, pharynx moist and non injected.

Eyes: PERRL, EOMI, conjunctiva pink with no discharge.

Neck: Supple, no adenopathy.

Respiratory: Lungs clear, no rales, no rhonchi, no wheezing, no accessory muscle use.

Heart: Regular rate and rhythm, no murmurs.

Abdomen: Soft, nontender, active bowel sounds, nondistended, no guarding or rebound.

GU: no CVA tenderness.

Extremities: No edema, no calf tenderness.

Neuro: No focal weakness, no facial asymmetry, moves all extremities normally, normal speech pattern, normal gait.

Date / Time : Ultrasound of : PREG 1ST TRI SINGLE ENDOVAG

Ultrasound was : Interpreted by Radiologist

FINDINGS: Uterus: Again noted is a partial uterine duplication. Endometrium: Within the left horn there is an intrauterine gestation with fetal pole and yolk sac identified.Fetal heart rate is 205 BPM.Sub membranous collections compatible with sub chorionic hematoma are seen with 2 collections identified measuring 12 x 13 x 3 mm and 23 x 17 x 8 mm. Cervix is closed. Ovaries: Right ovary is normal in size and appearance.Again noted is a left ovarian or paraovarian cyst currently measuring 22 x 14 x 12 mm Free Fluid: None. Crown-rump length corresponds to a sonographic age of 9 weeks and an EDD of 05/04/2020.LMP is 07/28/2019 corresponding to a clinical age of 9 weeks 1 day and EDD of 05/03/.

IMPRESSION:

1.Nine week living intrauterine gestation within left uterine horn of a partially duplicated uterus.

2.Two subchorionic hematomas are noted.

Medical Decision Making (MDM) :  

Medical decision making this is an 18-year-old female who is pregnant she had some minor pink spotting as well as lower abdominal discomfort. Ultrasound shows a 9 week intrauterine pregnancy with good heart beat. Patient is clinically well she is Rh positive no signs of infection. Plan patient is reassured. Plan of recheck at Community Clinic for prenatal care as scheduled. Vaginal rest. Recheck if increased pain or bleeding. Impression threatened AB.

ED Diagnosis (Current Problem List) :  

Assessment and Planning:

Dx: Threatened miscarriage

Disposition

Disposition Decision Date/Time:

D/C from ED to: Home

CPT code :

99284-25

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. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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 high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function.

76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester, transabdominal approach; single or first gestation

76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal

Chief Complaint & History of Present Illness :  

18yo F with R index finger avulsion injury sustained 08/30/2019 when opening a connector door on a train. TDAP UTD. Patient reports she performed basic wound care 08/30/2019. Moves without issue. Patient complains of mild pain. Patient requesting further evaluation.

Past Medical History :  

PMH: mitochondrial disease

Social History

freshman at UC Merced, parents at bedside

Review Of Systems

ROS: All systems reviewed and found to be negative except those mentioned in the history of present illness.

Vital Signs

Most Recent Set of Vitals:

BP: 126/85 08/31/ 12:38

Pulse: 78 08/31/ 12:38

Temp: 37.2 C 08/31/ 12:38

Resp: 16 08/31/ 12:38

02 Sat: 99%(Room Air) 08/31/ 12:38

Calculated BMI: 19.6 08/31/ 12:38

Physical Exam

General: Awake, alert, oriented x3, cooperative, and in no apparent distress.

Head: Normocephalic and atraumatic.

Eyes: Pupils equal and reactive to light, extraocular movements intact, sclera anicteric.

ENT: Airway patent and protected.

Neck: No meningeal signs

Respiratory: Clear to auscultation bilaterally, no respiratory distress.

Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops.

Musculoskeletal: Extremities atraumatic, ROM intact. Peripheral pulses intact throughout and symmetric.

Neurologic: Moves all extremities normally, speech and coordination normal.

Skin: 1 cm superficial avulsion injury to the palmar aspect of right 2nd digit. No erythema or purulent drainage. No acute appearing lesions or rashes noted.

Medical Decision Making (MDM) :  

18-year-old female with hx of mitochondrial disease, with superficial avulsion injury to the right 2nd digit sustained 08/30 while on a train. No repair necessary. Wound was irrigated by ER technician under my supervision and wound care provided. Advised patient on continued wound care and signs of infection to be aware of, especially given immunocompromised state. Patient to follow up with primary care in 3-5 days if wound not healing appropriately. ER return precautions reviewed.Patient and parents verbalized understanding of plan.

ED Diagnosis (Current Problem List) :  

Assessment and Planning:

Avulsion of skin None Associated Active

Disposition

Disposition Decision Date/Time:

D/C from ED to: Home

Condition at D/C: stable

99282   

Emergency department visit for the E/M of pt, requires these 3 key components: Expanded problem focused hx; Expanded problem focused exam; Medical decision making of low complexity. Counseling &/or coordination of care with other physicians, other QHCPs, or agencies consistent with the nature of the problem(s) & the patient’s &/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity

S61.200A  Unspecified open wound of right index finger without damage to nail, initial encounter

Chief complaint: Sore throat, cough

History of present illness: The patient is a 18 year old male presenting with sore throat and cough. Three weeks ago the sore throat started and has not improved. He also has a cough productive of colorless sputum. The cough started 2 weeks ago. Denies fever, chills, night sweats, headaches, dizziness, chest pain, palpitations, shortness of breath, hemoptysis, nausea, vomiting, abdominal pain, numbness, tingling or weakness. MDM: The patient is a 18 year old male who presented to the emergency department with a sore throat and cough. Airway is patent, tolerating oral secretions, tolerating p.o. Liquids, not tachycardic or febrile, oxygen saturation is adequate on room air, and no other physical exam/history findings to suggest acute airway or respiratory compromise. On examination the patient had exudative discharge and enlarged tonsils. Much of this discharge was removed with warm normal saline gargles in the ED. I was able to manually express a small amount of discharge and both tonsils which the patient tolerated without difficulty and told me he was feeling better after treatment. He had a negative streptococcal antigen test. Up to date on immunizations. Clinically, there was no evidence for peritonsillar abscess, Ludwig’s angina, retropharyngeal abscess, epiglottitis or other serious throat disease. I was able to manually expressed a small amount of discharge from bilateral tonsils which patient tolerated without difficulty. Patient is comfortable with plan to treat with amoxicillin, OTC analgesics, and primary care follow-up. Regarding the patient’s cough I think this is most likely due to postnasal drip. Chest x-ray was unremarkable for pneumonia, pulmonary edema, pleural effusion, pneumothorax, rib fracture. Abdominal examination was benign and I doubt mono or splenic rupture at this time. Counseled and educated patient on treatment plan and risks and benefits of treatment. Close follow-up advised. Patient understands that we are not able to diagnose all conditions in the emergency department, and that although at this time there are no worrisome symptoms and patient appears to be stable, patient will need to return at once if any recurrent, worsening, or new symptoms.

Medical history: No diabetes, hypertension or peripheral artery disease.

SOCIAL: Denies alcohol, tobacco, or recreational drug use.

ROS: Constitutional: No fevers, chills, night sweats.

Head: No headaches, head injury.

Ears: No ear aches. No ear discharge, new auditory deficits.

Nose: No epistaxis, rhinorrhea, sinus congestion.

Throat: Positive sore throats. No trouble swallowing, muffled voice.

Cardiovascular: No chest pain, palpitations, chest wall injuries.

Respiratory: Positive coughs. Positive productive coughs. No shortness of breath. No hemoptysis.

Abdominal: No abdominal pain, nausea, vomiting.

Skin: No rashes.

PE: Vitals: Reviewed by me.

Constitutional: Well developed, well nourished. No acute distress.

Head: Atraumatic, normocephalic.

Eyes: Extraocular movements in tact. Pupils are 5mm, ERRLA.

Nose: Patent nares bilaterally. Nasal mucosae is pink, moist.

Mouth/Throat: Moist membranes. Uvula midline.Oropharynx is pink, moist. Bilaterally enlarged tonsils with exudate discharge. Floor of the mouth is soft.

Neck: Supple.No JVD.

Cardiovascular: Normal heart rate and regular rhythm. CTA.

Respiratory: Non-labored breathing. No accessory muscle use. Lungs CTA.

Gastrointestinal: Soft, non-tender. Bowel sounds audible in all four quadrants and epigastrium. No masses or bruits.

Musculoskeletal: Full range of motion with passive and active testing. No obvious deformity.

Neurologic: Awake, alert, and oriented to time, place, and person. CNII-XII grossly in tact. Motor strength is 5/5. Sensation intact to fine touch.Gait and coordination are grossly normal.

Peripheral Vascular: Radial pulses 2+ and equal bilaterally. Capillary refill less than 3 seconds.

Skin: Warm, dry. No erythema or lacerations.

Vital Signs

Most Recent Set of Vitals:

BP: 118/61 09/01/ 10:10

Pulse: 81 09/01/ 10:10

Temp: 36.7 C 09/01/ 10:10

Resp: 16 09/01/ 10:10

02 Sat: 98%(Room Air) 09/01/ 10:10

Calculated BMI: 32.4 09/01/ 10:10

Vitals: Pulse Ox [This section may be copied as needed]

02 Source : Room Air 02 Delivery : 02 L/min FiO2 %

Pulse Ox Reading: 98 % Interpretation: Normal Date/Time:

CXR was: Interpreted by radiologist

Interpretation:

FINDINGS: The cardiomediastinal silhouette is within normal limits for age. There is no evidence of consolidation, pulmonary edema, pleural effusion, or pneumothorax. No acute rib fractures visualized.

IMPRESSION:

1.No radiographic evidence of acute cardiopulmonary disease.

Assessment and Planning:

Cough R05 – COUGH Active

Disposition

Disposition Decision Date/Time:

D/C from ED to: Home

Condition at D/C: Improved

CPT code :

99283 -25 Emergency department visit for the E/M of pt, requires these 3 key components: Expanded problem focused hx; Expanded problem focused exam; & Medical decision making of moderate complexity. Counseling &/or coordination of care with other physicians, other QHCPs, or agencies consistent with the nature of the problem(s) & the patient’s &/or family’s needs. Usually, the presenting problem(s) are of moderate severity

71046 Radiologic examination, chest; 2 views

There are lot of changes going to happen with Evaluation & Management (E/M) codes in future. CMS has released some of the important changes going to happen with E/M codes from 1st January 2021.

Some of important changes of E/M in 2021 

CPT 99201 (Office or other outpatient visit for the evaluation and management of a new patient) will no longer exist as of January 1, 2021.

• Deletion of 99201
• New guidelines specific to 99202-99215
• Changes in component scoring for both new and established patient codes (99202-99215)
• Changes to the medical decision-making table
• Changes to the typical times associated with each E/M code (99202-99215)

The proposed CMS rule further states:

…history and exam would no longer select the level of code selection for office/outpatient E/M visits. Instead, an office/outpatient E/M visit would include a medically appropriate history and exam, when performed. The clinically outdated system for number of body systems/areas reviewed and examined under history and exam would no longer apply, and these components would only be performed when, and to the extent medically necessary and clinically appropriate. Level 1 visits would only describe or include visits performed by clinical staff for established patients.

Their will be elimination of the use of history and/or physical exam to select the correct code level, The exception is that if neither are documented and medical necessity would warrant them being performed and documented, it could trigger additional review.

The new AMA guidelines state that time spent in an E/M service includes all time spent 3 days prior to, or 7 days after it. If a patient calls in to the office to speak with a provider about a medical condition and that telephone conversation results in an appointment for an E/M service that occurs within 3 days of the call, it is not billable as a virtual communication service (G2012, 99441-99443), but rather would be incidental to (or part of) the resulting E/M service. The same would apply if the communication took place within 7 days following the initial E/M service.

We are accustomed to quantifying face-to-face time and time spent counseling and coordinating. However, starting in 2021, the time values associated with each office/outpatient E/M code will indicate the total time spent on the day of the encounter. We will no longer need to determine how much of that time was spent in counseling and coordinating. 

Medicare’s new plan is to continue paying distinct rates for each office/outpatient E/M code in 2021. The proposed work RVUs, based on RUC recommendations, are below . In parentheses, you’ll see how the 2021 work RVUs compare to current work RVUs for each code:

• 99202: 0.93 (2019: same)
• 99203: 1.6 (2019: 1.42)
• 99204: 2.6 (2019: 2.43)
• 99205: 3.5 (2019: 3.17)
• 99211: 0.18 (2019: same)
• 99212: 0.7 (2019: 0.48)
• 99213: 1.3 (2019: 0.97)
• 99214: 1.92 (2019: 1.5)
• 99215: 2.8 (2019: 2.11).