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tci ED Coding & Reimbursement Alert - 2015 Issue 3

You Be the Coder: Can You Draw Elements of History and MDM From Anywhere In The Chart?

Question: The chart documentation seems a little brief, but this seems like a pretty sick patient. What E/M level would you assign to this chart? Ohio Subscriber Chief Complaint: Shortness of breath HPI: This 58-year-old male patient presents complaining of shortness of breath of gradual onset, but increasing severity over the past two days. He says the pain is severe and it is worse upon movement. He reports no change when lying flat or with rest. He is positive for dyspnea at rest, cough, malaise, and fever. He denies any abdominal pain, anxiety, dizziness, nausea, numbness, or diaphoresis. He...

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