Hello . A 20-year-old male was dropped off at the hospital ED with a knife hilt sticking out of his mid left anterior ch

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answerhappygod
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Hello . A 20-year-old male was dropped off at the hospital ED with a knife hilt sticking out of his mid left anterior ch

Post by answerhappygod »

Hello
. A 20-year-old male was dropped off at the hospital ED with a
knife hilt sticking out of his mid left anterior chest. The patient
was not fully conscious. No one accompanied the patient. The
patient was seen by the ED attending, Dr. Allen. Physical
examination was less than comprehensive. It was noted that wherever
there was a peripheral pulse, the knife handle quivered. The
attending physician initiated the trauma team mobilization and
ordered the necessary diagnostics and fluid/blood replacement
products. A partial history was obtained and documented by the ED
physician. Twenty minutes after the patient was brought into the
ED, the on-call trauma surgeon arrived. At that time the ED
physician, Dr. Allen transferred care of the patient to the
surgeon. Dr. Allen did document that the patient was unconscious
and in an immediate threat to life. Dr. Allen was also unable to
obtain a comprehensive history or a comprehensive examination due
to the patient’s clinical presentation. The medical decision making
was of a high and complex level per the documentation of Dr. Allen.
What is the E/M code for Dr. Allen service to this patient?
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