tci ED Coding & Reimbursement Alert - 2024 Issue Q2

You Be the Coder: ED E/M With Critical Care

Question: A patient reports to the ED with chest pain. During the course of an ED evaluation and management (E/M) service, the physician orders an electrocardiogram (ECG) and a complete chest X-ray. The physician does not note a cardiac event, but does diagnose the patient with angina pectoris; notes indicate a moderate level of medical decision making during the encounter. Just as the patient is being discharged, they collapse in cardiac arrest. The physician performs 60 minutes of critical care for the patient, whose diagnosis has changed to cerebral infarction (CI) due to thrombosis of the vertebral artery. How...

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