After a STEMI activation from the field on Monday morning, the cardiac catheterization team scoops the patient away shortly after the paramedics arrive in the Emergency Department (ED). “Well that was a smooth and seamless resuscitation. The patient was barely in the ED for more than 15 minutes,” you think to yourself. You diligently complete your critical care documentation, noting 20 minutes of critical care time, before seeing your next patient. A few weeks later the chart is bounced back and noted as an erroneous documentation of critical care time. The coding department notifies you that the case will be billed as a Level 3 visit (E/M code #99283). Why is that the case?
In this ED Charting and Coding Series, we have covered Introduction to ED Charting and Coding (PV Card); the History of Present Illness & Past Medical, Family, Social History; the Review of Systems; and the Physical Exam. At last we arrive at the crux of the chart: Medical Decision Making (MDM). In this final section, you show your work and your thought process.