Input Case
Patient: Robert Williams (GEMS-55667788) | Provider: Dr. Catherine Moore (Cardiology) | Scheme: GEMS Emerald
CONSULTATION REPORT PATIENT: Robert Williams, 62-year-old male DATE: 16 December 2024 REFERRING DOCTOR: Dr. Anna Peters (GP) REASON FOR REFERRAL: Evaluation of chest pain CHIEF COMPLAINT: Chest pain and shortness of breath for 3 days HISTORY OF PRESENT ILLNESS: 62-year-old male with 3-day history of intermittent substernal chest discomfort. Pain is described as pressure-like, non-radiating, lasting 5-10 minutes, occurring with moderate exertion. Associated with mild dyspnea on exertion (able to climb one flight of stairs before symptoms). No rest pain. No diaphoresis, nausea, or palpitations. No orthopnea or PND. PAST MEDICAL HISTORY: - Hypertension diagnosed 10 years ago, on Amlodipine 5mg daily - Type 2 diabetes mellitus, diet controlled - Hyperlipidemia, on Atorvastatin 20mg - No previous cardiac history - No previous surgical history SOCIAL HISTORY: - Non-smoker (quit 20 years ago, 10 pack-years) - Occasional alcohol (2-3 units/week) - Sedentary lifestyle, office worker - Married, 2 adult children FAMILY HISTORY: - Father: MI at age 65, deceased age 72 - Mother: Hypertension, alive age 85 - No siblings PHYSICAL EXAMINATION: - General: Well-appearing, not in distress - Vitals: BP 152/94 mmHg, HR 88 bpm regular, RR 16/min, SpO2 98% on room air - BMI: 29 - Cardiovascular: - JVP not elevated - Apex beat normal position - Normal S1, S2, no S3 or S4 - No murmurs, rubs, or gallops - Peripheral pulses present and equal - Respiratory: Clear to auscultation bilaterally, no wheezes or crackles - Abdomen: Soft, non-tender, no organomegaly - Extremities: No peripheral edema, no cyanosis INVESTIGATIONS: 1. ECG (performed in rooms): - Normal sinus rhythm, 86 bpm - Normal axis - No ST-T changes - No pathological Q waves - QTc 420ms 2. Serial Troponin I: - 0 hours: < 0.01 ng/mL (normal) - 6 hours: < 0.01 ng/mL (normal) 3. Chest X-ray: - Cardiothoracic ratio normal - No pulmonary congestion - No effusions 4. Lipid profile: - Total cholesterol: 5.8 mmol/L - LDL: 3.4 mmol/L - HDL: 1.1 mmol/L - Triglycerides: 2.1 mmol/L 5. HbA1c: 6.4% (pre-diabetic range) RISK ASSESSMENT: - HEART score: 4 (Low-Intermediate risk) - 10-year ASCVD risk: 15% (Intermediate) ASSESSMENT: 1. Atypical chest pain - stable angina vs non-cardiac chest pain 2. Essential hypertension, poorly controlled 3. Pre-diabetes / impaired glucose tolerance 4. Dyslipidemia - not at LDL target PLAN: 1. Functional testing: Exercise stress echocardiogram within 1 week 2. Optimize blood pressure: Increase Amlodipine to 10mg daily, add Perindopril 4mg daily 3. Lifestyle modification: Mediterranean diet, exercise program 4. Increase Atorvastatin to 40mg nocte for LDL target < 2.6 mmol/L 5. Start low-dose Aspirin 100mg daily 6. HbA1c monitoring, consider Metformin if increases 7. Follow-up in 2 weeks with stress echo results CONSULTATION LEVEL: Specialist consultation, extended - 45 minutes
Full Clinical & Coding Analysis
Patient: Robert Williams | Member ID: GEMS-55667788 | Scheme: GEMS Emerald
Risk Assessment Summary
HEART Score
4
Low-Intermediate Risk10-Year ASCVD Risk
15%
IntermediateICD-10 Diagnosis Analysis
| ICD-10 Code | Description | PMB Status | Confidence |
|---|---|---|---|
| R07.4 | Chest pain, unspecified | Non-PMB | 100% |
| I20.9 | Angina pectoris, unspecified | PMB 907E | 75% |
| R03.0 | Elevated blood-pressure reading, without diagnosis of hypertension | Non-PMB | 90% |
Clinical Justifications
R07.4: Primary presenting complaint: 3-day history of intermittent substernal chest discomfort described as 'atypical chest pain'.
Suggested: I20.9 - Working diagnosis (Angina pectoris) treated with Aspirin/Statins; triggers PMB eligibility.
Warning: R07.4 is a symptom code and does not automatically qualify for PMB funding without a confirmed PMB diagnosis.
I20.9: Assessment indicates 'Atypical chest pain - stable angina vs non-cardiac'. Treatment plan (Aspirin, increased Atorvastatin) is consistent with management of Ischemic Heart Disease.
Warning: Diagnosis requires confirmation via planned functional testing (Stress Echo) for permanent PMB registration.
R03.0: Recorded BP 152/94 mmHg on examination. Note: Patient has history of Hypertension, but I10 code was not in retrieved list.
Procedure Code Analysis
| RPL Code | Description | Linked ICD-10 | Compliance |
|---|---|---|---|
| 1232 | ECG (per 24 hour) | R07.4, I20.9, R03.0 | Compliant |
1232: ECG (per 24 hour)
Modifiers:
- M0092 - Diagnostic services rendered to out-patients
Note: 1232 describes a 24-hour ECG in the reference data, but the clinical note describes a standard resting ECG performed in rooms. Potential description mismatch in reference data vs service rendered.
Warning: Consultation code (e.g., 0192) was performed but is missing from the retrieved reference data set. It must be added to the final claim.
PMB Assessment
Overall Eligibility:partially-eligible
PMB Eligible Conditions
907E - Acute and subacute ischemic heart disease, including myocardial infarction and unstable angina
Linked ICD-10: I20.9 | Treatment: Medical management; surgery; percutaneous procedures
Linked ICD-10: I20.9 | Treatment: Medical management; surgery; percutaneous procedures
| Diagnosis | Treatment | Procedure | Status | Reason |
|---|---|---|---|---|
| I20.9 | Medical Management (Aspirin, Statins) + Diagnostic Workup (ECG) | 1232 | valid | ECG is standard of care for investigating Ischemic Heart Disease (PMB 907E). |
Scheme Considerations
- Patient is on GEMS Emerald. PMB 907E requires coverage at cost if services are rendered by a DSP or in an emergency.
- Diagnosis I20.9 should be primary or secondary to trigger PMB adjudication.
Pre-Authorization Requirements
- None for the consultation/ECG, but the planned Stress Echo (Code 1199 or similar) will likely require pre-authorization.
Billing Guidance
Recommendations
- ADD MISSING CODE: The clinical note confirms a 'Specialist consultation, extended - 45 minutes'. You must add the appropriate consultation code (e.g., 0192 for New Specialist Visit) to the claim, as it was not in the reference list.
- ICD-10 SELECTION: Submit I20.9 (Angina) as a secondary diagnosis to R07.4 (Chest pain) to flag this as a PMB workup for Ischemic Heart Disease.
- MODIFIER USAGE: Ensure Modifier 0092 is on the ECG line item to denote outpatient service.
- FUTURE ACTION: Obtain authorization for the planned Stress Echo immediately, citing I20.9.
| Potential Issue | Severity | Mitigation |
|---|---|---|
| Missing Consultation Code | high | Manually add the correct consultation tariff code (e.g., 0192) before submission. |
| PMB Rejection for R07.4 | medium | Schemes often reject R-codes for PMB funding. Ensure I20.9 is included to substantiate the cardiac nature of the investigation. |
Required Documentation
- Consultation notes detailing the 45-minute duration to justify an extended consult code if used.
- ECG strip and report (as per standard audit requirements).
- PMB application form for Chronic Disease List (CDL) or PMB registration for Ischemic Heart Disease if diagnosis is confirmed.
Scheme Submission Notes
- Submit to GEMS with PMB indicator Y.
- Link I20.9 to the ECG and Consultation lines.
Generated by MedCascade | Sample data | Not medical advice