tci E/M Coding Alert - 2016 Issue 3

Reader Question: Remember, Critical Care Needn't Be Continuous

Question: A 68-year-old woman with cirrhosis presents to the emergency department (ED) complaining of vomiting blood. She appears very pale, is hypotensive and tachycardic. The ED physician begins her resuscitation by starting two large-bore IVs, administering IV fluid boluses, and having her typed and cross-matched for blood. The physician documents providing 70 minutes of critical care in order to stabilize this hypotensive patient (6:44 a.m. to 7:54 a.m.). Once she has stabilized and we were in the process of admitting her to the hospital, the nurse reports that the patient is now diaphoretic and complaining of...

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