Consult – Chest Pain
Medical Specialty: General MedicineDescription: A 37-year-old admitted through the emergency department presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphoresis. Symptoms on and off for the last 3 to 4 days, especially when he is under stress. No relation to exertional activity. No aggravating or relieving factors.
REASON FOR CONSULTATION:
Chest pain.
HISTORY OF PRESENT ILLNESS:
The patient is a 37-year-old gentleman admitted through the emergency room. He presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphoresis. Symptoms on and off for the last 3 to 4 days, especially when he is under stress. No relation to exertional activity. No aggravating or relieving factors. His history is significant, as mentioned below. His workup so far has been negative.
CORONARY RISK FACTORS:
No history of hypertension or diabetes mellitus. Active smoker. Cholesterol status is borderline elevated. No history of established coronary artery disease. Family history is positive.
FAMILY HISTORY:
His father died of coronary artery disease.
SURGICAL HISTORY:
No major surgery except for prior cardiac catheterization.
MEDICATIONS AT HOME:
Includes pravastatin, Paxil, and BuSpar.
ALLERGIES:
None.
SOCIAL HISTORY:
Active smoker. Does not consume alcohol. No history of recreational drug use.
PAST MEDICAL HISTORY:
Hyperlipidemia, smoking history, and chest pain. He was hospitalized in October of last year, hospitalized. Subsequently underwent cardiac catheterization. The left system was normal. There was a question of a right coronary artery lesion, which was thought to be a spasm. Subsequently, the patient did undergo nuclear and myocardial perfusion scan, which was normal. The patient continues to smoke actively for the last 3 to 4 days, especially when he is stressed. No relation to exertional activity.
REVIEW OF SYSTEM
CONSTITUTIONAL: No history of fever, rigors, or chills.
HEENT: No history of cataract, blurred vision, or glaucoma.
CARDIOVASCULAR: As above.
RESPIRATORY: Shortness of breath. No pneumonia or valley fever.GASTROINTESTINAL: No epigastric discomfort, hematemesis, or melena.
UROLOGICAL: No frequency or urgency.
MUSCULOSKELETAL: No arthritis or muscle weakness.
CNS: No TIA. No CVA. No seizure disorder.
ENDOCRINE: Nonsignificant.
HEMATOLOGICAL: Nonsignificant.PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse of 75, blood pressure of 112/62, afebrile, and respiratory rate 16 per minute.
HEENT: Head is atraumatic and normocephalic. Neck veins flat.
LUNGS: Clear.
HEART: S1 and S2, regular.
ABDOMEN: Soft and nontender.
EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis.
CNS: Benign.
PSYCHOLOGICAL: Normal.
MUSCULOSKELETAL: Within normal limits.DIAGNOSTIC DATA:
EKG, normal sinus rhythm. Chest x-ray unremarkable.
LABORATORY DATA:
First set of cardiac enzyme profile negative. H&H stable. BUN and creatinine are within normal limits.
IMPRESSION:
1. Chest pain in a 37-year-old gentleman with a negative cardiac workup, as mentioned above, is questionably right coronary spasm.
2. Hyperlipidemia.
3. Negative EKG and cardiac enzyme profile.RECOMMENDATIONS:
1. The patient is treated with medications with low doses of calcium channel blockers and statins, and asked how he feels.
2. No further investigation unless there is a positive cardiac enzyme profile; so far, it has been negative.
3. Lifestyle modification, diet, activity, weight reduction, and especially smoking cessation were discussed. Compliance with medications was stressed. All the questions were answered in detail.
Medical Coding Summary: Chest Pain Consultation
CPT Code (Evaluation and Management)
99222 Initial hospital inpatient or observation care
Rationale
The patient was admitted through the ER, so he is now in inpatient status. In addition, this encounter is a consultation request for chest pain. Inpatient E/M levels are based on medical decision making or time, and the moderate complexity MDM documented here supports 99222.
Important Exam Tip
Many payers, including Medicare, no longer recognize the inpatient consultation codes (99252 through 99255). Instead, report the initial hospital care codes (99221 through 99223). In this case, level 99222 is appropriate based on moderate complexity.
ICD-10-CM Diagnosis Codes
Primary Diagnosis
R07.89 Other chest pain
Secondary Diagnoses
- E78.5 Hyperlipidemia, unspecified
- F17.200 Nicotine dependence, unspecified, uncomplicated
- Z82.49 Family history of ischemic heart disease
Rationale
The provider did not confirm a cause for the chest pain, so you code the symptom. Because the workup is negative, do not code MI or CAD. However, the provider documents hyperlipidemia, so you report it. Also, the patient is an active smoker, which supports the nicotine dependence code. Finally, his family history affects his cardiac risk, so include Z82.49.
HCPCS Codes
No HCPCS codes are reported. The record documents no supplies, DME, or special services that require HCPCS Level II codes.
Final Code Set
CPT
- 99222 Initial Hospital Inpatient or Observation Care, per day
ICD-10-CM
- R07.89 Other chest pain
- E78.5 Hyperlipidemia, unspecified
- F17.200 Nicotine dependence, unspecified, uncomplicated
- Z82.49 Family history of ischemic heart disease and other diseases of the circulatory system
HCPCS
- None
Key Medical Coding Tips for Chest Pain (CPC Exam Focus)
Rule Out vs Confirmed Diagnosis
If the diagnostic workup is negative, code the symptom (R07.89). In other words, do not code suspected coronary artery disease.
Consult vs Initial Care
Even though the note says “consult,” use 99221 through 99223 rather than consult codes. This is a very common CPC trap.
Risk Factors Matter
Smoking, hyperlipidemia, and family history are clinically relevant here. Therefore, code all three.
Do Not Overcode
Do not code coronary artery spasm, because the provider did not confirm it. Likewise, do not code CAD, since the provider did not diagnose it. Also, do not code shortness of breath separately unless the provider treats it independently.
Medication Clues
Medications can support your code choices. For example, statins support hyperlipidemia. Similarly, calcium channel blockers support a suspected cardiac cause, although they do not confirm a disease.