e/m code for following scenario ? Follow-up Visit

Question

Worth 4.000 points.
REASON FOR FOLLOWUP
Physician supervision of a hospice patient for care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with cardiorespiratory arrest last night with CPR and advanced cardiac life support.

HISTORY OF PRESENT ILLNESS
This is a 65-year-old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes. Her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well. Previously while treating this patient, I had met with the family and discussed how aggressive the patient would wish her level of care to be, given that she has an ovarian malignancy located in the right ovary. As the patient was showing signs of improvement with some speech and ability to follow commands, decision was made to continue to pursue an aggressive level of care, treat her dysphagia, hypertension, debilitation and this was being done. However, last night, the patient had an apparently catastrophic event around 2:40 in the morning. Rapid response was called, and the patient was intubated, started on pressure support and given CPR. This morning I was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care. The patient was seen and examined. She was intubated and sedated. Limbs were cool. Cardiovascular exam revealed tachycardia. Lungs had coarse breath sounds. Abdomen was soft. Extremities were cool to the touch. Pupils were 6 to 2 mm, doll’s eyes were not intact. They were not responsive to light. Based on discussion with all family members involved including both sons, daughter and daughter-in-law, a decision was made to proceed with terminal wean and comfort care measures. All pressure support was discontinued. The patient was started on intravenous morphine, and respiratory was requested to remove the ET tube. Monitors were turned off, and the patient was made as comfortable as possible. Family is at the bedside at this time. The patient appears comfortable, and the family is in agreement that this would be her wishes. Per my understanding of the family and the patient dynamics over the past month, this is a very reasonable and appropriate approach given the patient’s failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities.

ASSESSMENT
1. Cardiorespiratory arrest.
2. Ovarian malignancy.
Total time spent at the bedside today in care plan oversight services, medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes.

EM code

Answer 1

Based on the provided scenario, the appropriate Evaluation and Management (E/M) code would depend on factors such as the complexity of medical decision-making, time spent, and the nature of the visit. Since you mentioned that the service rendered was a follow-up visit involving significant care planning and decision-making, the E/M codes for "hospital inpatient" or "hospital outpatient" visits would be reviewed.

In this situation, since the patient was seen for a follow-up care conference at the bedside, the following codes may apply:

For inpatient settings:

• 99221: Initial Hospital Care (if this had been an initial visit)
• 99232: Subsequent hospital care visits, typically coded for moderate complexity with at least 15-29 minutes of total time spent on the visit, but it seems the scenario indicates the visit took more than 37 minutes of care plan oversight.

For hospital outpatient or observation:

• 99219: This is also applicable if you utilize the time spent in medical decision making and oversight services exceeding 35 minutes.

Given that the physician spent substantial time in care conference and medical decision-making, focusing specifically on terminal care decisions, this aligns with a higher complexity visit.

In summary, based upon the detailed case management and patient care decisions depicted in your scenario, if the visit was inpatient:

The best code would likely be 99232 (if following up inpatient care for moderate complexity).

If this is an outpatient or observation context:

Consider 99219 or 99221 based on criteria and guidelines available at the time.

Remember to ensure that documentation supports the selected code, especially regarding time spent and complexity of medical decision-making.