Sure, here is a sample coded chart for CPT code 99284, which is used to report emergency department visits that require a higher level of medical decision making and resource utilization:
Patient presents to the emergency department with complaints of severe abdominal pain and vomiting. The patient has a history of gastric ulcers and takes daily medication for it. The patient reports that the pain started suddenly and is radiating to the back. The patient rates the pain as a 9 out of 10 on the pain scale.
On physical examination, the patient is found to have rebound tenderness in the lower abdomen and guarding. The patient is also tachycardic with a heart rate of 110 beats per minute and hypotensive with a blood pressure of 90/60 mmHg.
Initial laboratory results show an elevated white blood cell count of 16,000/microL and an elevated serum lipase level of 600 U/L. A CT scan of the abdomen and pelvis is ordered and shows findings consistent with acute pancreatitis.
Medical decision making: The patient presents with severe symptoms and signs of a potentially life-threatening condition. The physician determines that admission to the hospital is necessary for further management and monitoring. The physician also orders intravenous fluids, pain control, antiemetic medication, and consults with a gastroenterologist for further management of the patient’s acute pancreatitis. The physician documents a moderate level of medical decision making.
CPT code: 99284 – Emergency department visit for the evaluation and management of a patient, which requires a moderate level of medical decision making and high level of resource utilization.
ICD-10-CM codes: K85.0 – Acute pancreatitis, unspecified; R10.9 – Unspecified abdominal pain.