Complexity (and number) of Problems Addressed: High.
– Complaint that could pose threat to life or bodily function addressed: Chest Pain
Emergent differential diagnoses considered but not limited to:
ACS, Pneumothorax, Pulmonary Embolus, Tamponade, Aortic Dissection.
Given history, exam, workup presentation not overtly consistent with above diagnoses.
Last Stress Test: never
Last Heart Catheterization: never
HEART Score:
Amount and/or complexity of Data to be reviewed/analyzed: Extensive
– Category 1: Tests and documents: 3 or more unique tests ordered
– Category 2: Independent interpretation of tests: YES. Chest X-Ray
– Category 1: Review of prior external notes as documented above
– Category 1: Assessment requiring Independent Historian: due to patient’s altered mental status case discussed with ***
– Category 3: Qualified Healthcare Professional Discussion of management or test interpretation: YES.
Risk of complications and/or Morbidity or Mortality of Patient Management: High
– Medications/Drug Therapy provided requiring monitoring for toxicity.
– Decision regarding hospitalization: Admit
– Parenteral controlled substances administered in ED.
**Moderate Risk
– Diagnosis/Treatment limited by social determinants of health: homelessness
– Prescription Drug Management:
Overall Visit Complexity: High
- High CPT Coding [99223, 99285, 99233, 99236]
- Coding based on highest 2 of 3 sections [COPA, Data Review, Risk]
- Data Review requires 2 of 3 categories to be fulfilled
Number & Complexity of Problems Addressed
* 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
OR
* 1 acute or chronic illness that poses a threat to life or bodily function
Amount and/or Complexity of Data to be Reviewed/Analyzed
(Each unique test, order or document contributes to the combination of 2 or combination of 3 in Category 1 below)
- Tests, documents [external notes], or independent historian
- Independent interpretation of tests like CXR
- Discussion of management or test interpretation with external physician/other qualified health care professional
Risk of Complications and/or Morbidity or Mortality of Patient Management
LEVEL 5 High risk of morbidity from additional diagnostic testing or treatment
Examples only:
* Drug therapy requiring intensive monitoring for toxicity
* Decision regarding elective major surgery with identified patient or procedure risk factors
* Decision regarding emergency major surgery
* Decision regarding hospitalization or escalation of hospital level of care
* Decision not to resuscitate or to de-escalate care because of poor prognosis
* Parenteral controlled substances
LEVEL 4 Moderate risk of morbidity from additional diagnostic testing or treatment
Examples only:
* Prescription Drug Management
* Decision regarding minor surgery with identified patient or procedure risk factors
* Decision regarding elective major surgery without identified patient or procedure risk factors
* Diagnosis or treatment significantly limited by social determinants of health
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