Question
A 72-year-old woman presents to the emergency department with onset of aphasia and right hemiplegia 2 hours ago. The doctor arrives at 6:00 p.m. and
A 72-year-old woman presents to the emergency department with onset of aphasia and right hemiplegia 2 hours ago. The doctor arrives at 6:00 p.m. and finds the patient globally aphasic with no movement of the right extremities. NIHSS score is 18. CT brain was done before the physicians arrival and he reads it as normal. Laboratory values including glucose, platelets, and INR are all normal. Her husband is in the room and tells you she has a history of hypertension and atrial fibrillation. Medications include warfarin and altace. She had no prior history of stroke and no recent trauma or surgical procedures. The patients blood pressure is 150/90. It is determined the patient is an appropriate candidate for IV tPA. Risks and benefits of IV tPA are explained to her husband. He consents to proceeding with treatment. The nurse mixes IV tPA and gives her 0.9 mg/kg with 10% as a bolus. She mixes the tPA and draws the bolus into a syringe. The physician administers the bolus and the nurse starts the IV infusion of tPA. The doctor then writes admission orders, dictates a note, and leaves the ED at 7:20 p.m. His note documents that he personally attended to this critically ill patient for 1 hour 20 minutes including acute stroke evaluation, determining the appropriateness of administering IV tPA, discussing with the family and initiating treatment. This was exclusive of any time spent on E/M services
Wondering which section of CPT coding book to get coding info
Step by Step Solution
There are 3 Steps involved in it
Step: 1
Get Instant Access to Expert-Tailored Solutions
See step-by-step solutions with expert insights and AI powered tools for academic success
Step: 2
Step: 3
Ace Your Homework with AI
Get the answers you need in no time with our AI-driven, step-by-step assistance
Get Started