tci ED Coding & Reimbursement Alert - 2010 Issue 6

Reader Questions: NOPP Can Push Physician's MDM Up

Question:A 45-year-old male patient reports to the ED with chest pain and mild shortness of breath; the physician's initial clinical judgment is a possible cardiac etiology , so he performs a comprehensive history and exam, as well as ordering labs, a two view chest x-ray, and an electrocardiogram (EKG). The workup reveals no cardiac condition, but rather severe indigestion. The physician orders a GI \"cocktail\" and sends the patient home. How should I code this encounter?Washington, DC SubscriberAnswer:Since the nature of the presenting problem (NOPP) was so high for this patient (possible heart attack), this is likely a high-complexity...

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