e/m code for following scenario ? Discharge Summary

Question

Worth 4.000 points.
ADMITTING DIAGNOSIS
Hiatal hernia, gastroesophageal reflux disease.

SECONDARY DIAGNOSIS
Postoperative intestinal obstruction.

PROCEDURES PERFORMED
Hiatal hernia repair and Nissen fundoplication revision.

HISTORY OF PRESENT ILLNESS
The patient is an 18-year-old male who has had a history of a Nissen fundoplication performed 6 years ago for gastric reflux. Approximately 1 year ago, he was involved in a motor vehicle accident, and CT scan at that time showed that he had a hiatal hernia. Over the past year, this has caused him an increasing number of problems, including chest pain when he eats and shortness of breath after large meals. He is also having reflux symptoms again. He presents to us for repair of the hiatal hernia and revision of the Nissen fundoplication.

HOSPITAL COURSE
The patient was admitted to the adolescent floor after his procedure. He was stable at that time. He did complain of some nausea. However, he did not have any vomiting at that time. He had an NG tube in and was n.p.o. He also had a PCA for pain management as well as Toradol. On postoperative day #1, he complained of not being able to urinate, so a Foley catheter was placed. Over the next several days, his hospital course proceeded as follows. He continued to complain of some nausea; however, he did not ever have any vomiting. Eventually, the Foley catheter was discontinued, and he had excellent urine output without any complications. He ambulated frequently. He remained n.p.o. for 3 days. He also had the NG tube in during that time. On postoperative day #4, he began to have some flatus, and the NG tube was discontinued. He was advanced to a liquid diet and tolerated this without any complications. At this time, he was still using the PCA for pain control. However, he was using it much less frequently than on days #1 and #2 postoperatively. After tolerating the full liquid diet without any complications, he was advanced to a soft diet, and his pain medications were transitioned to p.o. medications rather than the PCA. The PCA was discontinued. He tolerated the soft diet without any complications and continued to have flatus frequently. On postoperative day #6, it was determined that he was stable for discharge to home as he was taking p.o. without any complications. His pain was well controlled with p.o. pain medications. He was passing gas frequently, had excellent urine output, and was ambulating frequently without any issues.

DISPOSITION
Discharged to home.

CONDITION ON DISCHARGE
Stable.

DISCHARGE DIAGNOSIS
Hiatal hernia, gastroesophageal reflux disease.

DISCHARGE INSTRUCTIONS
The patient was discharged to home with instructions for maintaining a soft diet. It was also recommended that he does not drink any soda postoperatively. He is instructed to keep his incision site clean and dry, and it was also recommended that he avoid any heavy lifting. He will be able to attend school when it starts in a few weeks. However, he is not going to be able to play football in the near future. He was given prescription for pain medication upon discharge. He is instructed to contact his physician if he has any fevers, any nausea and vomiting, any chest pain, any constipation or any other concerns.

DISCHARGE MANAGEMENT
4:15 p.m.–4:43 p.m.

EM code

Answer 1

Based on the provided information from the discharge summary, the relevant E/M (Evaluation and Management) coding would typically consider the complexity of the patient's visit, the level of care provided during the hospitalization, and the typical requirements for coding.

For a discharge summary visit (which typically falls under the category of discharge management), the E/M coding is determined by the complexity of the patient's condition and the work done during the discharge process.

The most relevant codes for this scenario are as follows:

CPT Codes:

• 99238: Hospital discharge day management; 30 minutes or less

  • Use when the physician performs the discharge management as described in the scenario that took less than or equal to 30 minutes.

• 99239: Hospital discharge day management; more than 30 minutes

  • Use when the physician's discharge management takes more than 30 minutes.

Based on the details in your summary, if the discharge management took less than 30 minutes, you would use 99238. If it took longer than 30 minutes, you would use 99239.

ICD-10 Codes:

• K44.9: Hiatal hernia without obstruction or gangrene
• K21.9: Gastroesophageal reflux disease (GERD) without esophagitis
• K56.609: Unspecified intestinal obstruction (for the postoperative intestinal obstruction)

Given that the primary focus is on the patient's discharge and given there are no additional complications or extended notes indicating a more complex situation, the relevant codes would be assigned primarily based on the services rendered and the patient's conditions listed above.

Selection Summary:

• E/M Code: 99238 or 99239 (depending on time)
• ICD-10 Codes: K44.9, K21.9, K56.609

Make sure to verify with any specific payer guidelines and coding references to confirm accuracy and compliance with standard practices.