tci ED Coding & Reimbursement Alert - 2010 Issue 4

Reader Questions: Check Descriptors on Tough P Mod Calls

Question: A patient is brought to the ED via ambulance with acute myocardial infarction (AMI). The ED physician talks to the emergency medical technician (EMT), who reports that the patient "flat-out refused" any aspirin, but the patient could not catch his breath enough to tell the EMT why he didn't want aspirin (There were no caretakers or relatives at home when the AMI occurred, so the patient is in the ambulance alone). During the history portion of the E/M, the patient's medical record reveals he is severely allergic to aspirin. We are reporting on measure 28 for the Physician...

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