SOLVED2245

CPT and ICD-10-CM code 3. Sally Smith is seen the ER complaining of pressure in her chest and the feeling that her heart is racing. After her vital signs are taken, an immediate electrocardiogram is performed, and her heart rate is found to be in excess of 160 bpm, with increased activity at the atrioventricular junction. After performing a comprehensive history and physical exam, the physician continues to evaluate the patient, who has been placed on continuous electrocardiographic monitoring. The ER physician documents the diagnosis of paroxysmal nodal tachycardia and calls the cardiologist for a consult and possible admission of Ms. Smith. Given the uncertainty of the diagnosis and the various other possible options, the physician’s MDM is highly complex. (Coding for the ER physician.)

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