tci ED Coding & Reimbursement Alert - 2004 Issue 11

Case Study: Chest Pain and Observation

When the heart is weak, report high-level E/M confidentlyChest pain is always an emergency, regardless of the patient's final diagnosis. Solve this case study and see if you know what to report when push comes to shove with a patient's heart.Physician's documentationPresenting complaint: Chest painHistory of present illness: 44 yo otherwise healthy male with no prior history of CP presents with intermittent episodes of substernal chest pressure, 5/10 severity, lasting up to 5 minutes throughout the day. Worse with movement or inspiration. No diaphoresis or SOB. Family history of CAD. No pain right now; took aspirin at home...

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