1. Abdomen pain LLQ – Adult
Narrator: A 62 year old male reports to the Emergency department complaining of abdomen
pain. Patient is lying on the patient bed moaning in pain.
Doctor: Hello. What brings you to the emergency department today?
Patient: Hi Doctor, my stomach really hurts
Doctor: I see, where does your stomach hurt?
Patient: Just down on the lower left side
Doctor: Okay, when did your pain begin?
Patient: The pain has been on and off for several months
Doctor: How long does the pain usually last?
Patient: It varies. Anywhere from 30 minutes to 2 hours
Doctor: Is there something that usually brings it on?
Patient: Not that I have noticed
Doctor: Any change with meals or activity?
Patient: No
Doctor: Does anything seem to make it better or worse?
Patient: Sometimes it gets better with rest.
Doctor: When did this episode of pain begin?
Patient: This afternoon while I was on the stationary bike at the gym
Doctor: Has the pain gotten worse or stayed the same since it began?
Patient: The pain has been getting worse.
Doctor: Have you been seen for this in the past?
Patient: No, I tried to see my doctor, but she has been on vacation.
Doctor: Does the pain move anywhere?
Patient: Sometimes I feel it in my left lower back.
Doctor: Anywhere else?
Patient: No.
Doctor: Have you had any nausea, vomiting, diarrhea or constipation?
Patient: I’ve had some nausea but I haven’t thrown up.
Doctor: How would you describe the pain?
Patient: I feel uncomfortable and bloated
Doctor: How would rate this pain, 1 out of 10, with 10 being the worst pain imaginable?
Patient: I’d say it’s a 7 out of 10
Doctor: Have you had a fever?
Patient: I’ve had chills and the nurse said my temperature was one hundred and one when I got
here.
Doctor: Have you had any burning on urination, feeling like you need to go all the time or that
not much is coming out?
Patient: No
Doctor: Have you noticed any blood in your urine or blood in your stools or black tarry stools.
Patient: No
Doctor: Is your urine stream still strong?
Patient: Yes
Doctor: have you had any abdominal surgeries in the past?
Patient: I had my gallbladder removed for gallstones several years ago but that's it
Doctor: Have you had any other surgeries?
Patient: No
Doctor: Do you have any medical conditions we need to know about?
Patient: Yes, I have diabetes and hypertension
Doctor: Do you smoke, drink or do drugs?
Patient: I occasionally drink alcohol
Doctor: Do any of your family members have similar problems or serious medical problems of
the abdomen like cancer or aneurysms?
Patient: My Aunt Sally had colon cancer at 82.
Doctor: Have you had any passing out or lightheadedness?
Patient: No
Doctor: Any chest pains or discomfort?
Patient: No
Doctor: Any shortness of breath?
Patient: No
Doctor: Any night sweats or chills?
Patient: No
Doctor: Any numbness or weakness?
Patient: No
Doctor: Is there anything else you think I should know and did not ask?
Patient: No
Doctor: Okay, I’m going to take a look at you.
(Narrator verbalizes the exam below)
Narrator: Doctor begins touching patient’s stomach starting with left upper stomach then left
lower stomach then right upper stomach then right lower abdomen.
Narrator: Patient flinches when the doctor touches the patient’s left lower stomach. Doctor also
checks femoral pulses and for nodes
Doctor: left lower quadrant tenderness. No guarding or rebound. No masses. Good pulses and
symmetrical. No enlarged nodes.
Narrator: Doctor checks leg neuro exam
Doctor: Strength and sensory exam is normal in the legs.
Narrator: Doctor examines the patients back
Doctor: The back has full range of motion, is not tender and there are no masses or CVA
tenderness.
Doctor: I need to check you for a hernia and do a rectal exam.
Narrator: Doctor puts on gloves before examining the patient.
Narrator: Doctor has the patient turn head and cough while checking for a hernia and checks
genitalia.
Doctor: No hernia, no masses, discharge or lesions.
Narrator: Doctor has patient turn on side and does rectal exam.
Doctor: No masses, prostate is slightly enlarged and nontender.
Narrator: Doctor takes off gloves and washes hands.
Narrator: Doctor takes out stethoscope from coat pocket and places chest piece on patient’s
abdomen
Doctor: you have normal bowel sounds. Please sit up so I can listen to your heart and lungs.
Narrator: Doctor places chest piece on patient's chest.
Doctor: Please take a few deep breaths
Narrator – Doctor moves stethoscope from chest to back and listens for 4 more breaths
Doctor: Great, lungs are clear. Now hold your breath
Narrator: Doctor moves stethoscope to chest and listens to heart rate and sounds. Examination
of skin, head, ear, eye, nose, throat, and neck are normal
Doctor: Your heart sounds are normal as well. We will order a CT of your abdomen. You will
have to drink some contrast prior to this CT scan. We will also order some blood work. Would
you like something for your pain?
Patient: yes
Doctor: I want to confirm that you do not have any allergies to medication. Is that correct?
Patient: Yes
Doctor: Okay I will get you something for that as well. I will return after we get the results of
your tests.
Narrator: Doctor walks out of the room and turns to scribe
Doctor (to scribe): Let's order a CBC, Chem 7, Urine analysis, CT abdomen and pelvis with PO
contrast, 4 milligrams of Zofran and 4 milligrams of Morphine with 2 milligrams every 10
minutes for pain over 2 out 10; up to 12 milligrams, both IV.
Doctor to scribe: I am ordering the CBC to look for anemia from possible GI bleeding and
evidence of infection or inflammation. The Chem 7 is to ensure that the kidney function is
normal and that the electrolytes are normal. The UA is to make sure there is no evidence of an
infection or blood. The CT is to rule out serious problems like aneurysms, abscesses,
obstruction or perforations.
--- Recheck --Narrator: The doctor reviews Labs and CT scan with the scribe before entering the room. The
Patient is sleeping on the hospital bed. The doctor walks into patient room, gently shakes
patients shoulder to wake them and reviews the nurse notes and repeats vital signs
Doctor: Your labs are normal. How is your pain?
Patient: I feel great now. Can I go home?
Doctor: Probably, first let me recheck your abdomen.
Narrator: Doctor rechecks abdomen
Doctor: Abdomen is soft and there is no tenderness now.
Doctor: Your CT scan shows you have diverticulitis. Have you been diagnosed with diverticulitis
or diverticulosis in the past?
Patient: My gastroenterologist mentioned something about diverticulosis after my last
colonoscopy.
Doctor: Ok. Diverticulitis is when one of your diverticula gets infected and causes you pain.
With normal labs and no other serious findings on the CT and with your abdomen being
nontender now, you are safe to try treatment at home.
Patient: Okay. What is the treatment?
Doctor: I will prescribe an antibiotic today and you will need to follow up with your
gastroenterologist this week. If your pain gets severe, there is blood in your stool, you cannot
keep down liquids, your fever returns, or if you feel that you are getting worse in any way, you
need to return here immediately. Diverticulitis can result in bowel perforation, bleeding and
other severe problems.
Patient: Ok thank you.
Doctor: No problem. I hope you feel better soon. Do you have any other questions or concerns?
Patient: No, Thank you
Narrator: Doctor leaves the room and turns to the scribe
Doctor to scribe: Discharge the patient with a diagnosis of diverticulitis. Prescribe the patient
Cipro 500 milligrams twice daily and Flagyl 500milligrams twice daily for 10 days. PRN Vicodin
325mg, 1 or 2 every 6 hours for pain and Zofran 4 milligrams ODT every 6 hours as needed for
nausea or vomiting.
Doctor: Discharge instructions to include information on Diverticulitis, medication information
and the above instructions on when to follow up or return to the ED.
Doctor to scribe: Under differential diagnosis and decision making please include: Based on the
history, physical exam, labs, imaging and response to treatment the patient appears most likely
to have diverticulitis. With the pain being left sided, normal CBC and no findings of appendicitis
on CT, appendicitis is unlikely. With the above findings and with a normal urinalysis without
blood, a kidney stone is also unlikely. The CT did not show any evidence of an abscess or
aneurysm which makes those diagnoses unlikely. The history was not consistent with an
ischemic bowel.
DOT NOT READ!
Coding Summary - As documented 99284 potential 99285
This chart qualifies for a level 99285 service based on the documented medical decision making which
translates to high MDM from a coding perspective. Due to deficiencies in both documentation of the
Review of Systems and Physical Exam this chart would be billed out a lower level than the MDM
supports.
Documentation supporting High MDM:
CT ordered, labs, multiple meds given including parental controlled, well documented DDX
Suggested documentation to support Medical Necessity
Physician describes to scribe why each test was ordered and what is being looked for, including this in
the documentation helps support the medical necessity for the individual testing as well as the overall
service provided.
Deficient documentation
ROS - To qualify for a level 99285 the record must include a ROS of at least 10 organ systems .
PE- In order to qualify for a level 99285 the record must include documentation of a comprehensive
physical exam , which must have at least 8 organ systems examined and documented.