e/m code for following scenario ? Inpatient Cardiology Consultation

Question

Worth 4.000 points.
PROBLEM Chest pain rule out myocardial infarction.

SUBJECTIVE
The patient is a 64-year-old Caucasian male with substernal chest pain on exertion for 1 month prior to admission. The night before admission, there was a particularly severe pressuretype substernal chest pain that radiated to the neck and lasted 20 minutes with associated diaphoresis. Cardiac risk factors include 30 pack-year history of smoking, family history positive for hypertension. According to the medical records provided by his family physician, the patient was placed on diltiazem 60 mg q.6h., Isordil 60 mg t.i.d. and aspirin 325 mg daily.

OBJECTIVE
On physical examination, the patient was a well-developed, elderly Caucasian male in no acute distress. Neck: No jugular venous distention. Heart: Regular rate and rhythm with the PMI in the 5th left intercostal space in the midclavicular line. S1 and S2 are heard throughout the precordium. No murmurs, rubs or gallops were noted. Extremities showed no evidence of clubbing, cyanosis or edema. The pulses were 2+ bilaterally. Bilateral femoral bruits were present. No carotid bruits were noted. Abnormal thallium stress test and abnormal CPK.

ASSESSMENT
Probable acute myocardial infarction.

PLAN
Stabilize and consider for cardiac catheterization.

EM code

Answer 1

Based on the provided documentation for the inpatient cardiology consultation, let's break down the key components of the information you've shared:

1. Problem: The patient's presenting issue is chest pain with a concern for myocardial infarction.
2. Subjective: The details include the patient's age, symptoms, risk factors, and current medications. There are significant concerns regarding his cardiac history and risk factors.
3. Objective: The physical examination is detailed, showing important findings relevant to cardiology.
4. Assessment: A clear diagnosis of probable acute myocardial infarction is made.
5. Plan: The plan includes stabilization and consideration for cardiac catheterization.

For coding the Evaluation and Management (E/M) service, you will typically refer to the guidelines established by the American Medical Association (AMA) which include both new and established patient codes based on the complexity of the visit.

Recommended E/M Code:

For an inpatient consultation that focuses on a complex issue such as an acute myocardial infarction, you would likely be looking at codes from the range of 99221-99223 for initial hospital care, specifically for inpatient consultations.

Code Suggestion

• 99223: Initial hospital care, typically for a patient with a high level of complexity requiring a detailed history and examination, which fits the presentation given the critical nature of the findings and level of assessment.

Points

• 4.00 Points: This aligns well with the complexity and detail of the scenario described.

Summary

Based on the scenario provided, the appropriate E/M code is likely 99223, as it reflects a high complexity patient with an acute condition requiring comprehensive evaluation and management. Always ensure that the documentation supports the level of service billed.