Scenario: 50 year old patient presented to

Scenario: 50 year old patient presented to the ED for chest pain and shortness of breath starting yesterday afternoon. She was doing her yard work yesterday all afternoon and has been having chest pain since 9:00 pm last evening. She took an Ibuprofen for pain and went to sleep. Woke up with shortness of breath and decided to come to ED today. Procedures: Routine 1 view chest x-ray is negative for fracture. 12 Lead routine EKG is normal. Impression: Atypical Chest pain may be due to doing her yard work. Shortness of breath Office Visit: Level of ER visit includes a documented Problem Focused history, Expanded Problem Focused Exam, and Moderate Complexity Medical Decision Making. Remember the Golden Rule for Coding: If it’s not documented, it didn’t happen! 1. What code(s) did you get? 2. What did you like about using the encoder? What did you dislike? 3. Review references to look at the actual code. Are there any symbols next to procedures this week? Are there in-section guidelines, if so how did they apply to your code selections? 3. Would any modifiers apply to the codes you selected? Why or why not?

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