PULMONARY EMBOLISM CONUNDRUM
Working on this chart in real-time I encountered this conundrum decided to share with my ACDIS mates. See question at the bottom of the page.
HPI from H&P
This Patient is 47 yrs. old Hispanic Female presents to ER with Cough, chest pain associated with the coughing, and Shortness of breath. The patient stated that a cough is nonproductive and be present for the last 6 months but worse since yesterday. Since diagnosed with PE 6months ago and cough has not improved.
NUCLEAR MEDICINE PERFUSION LUNG SCAN
Patchy areas of decreased lung perfusion at both lung bases, corresponding to chronic infiltrates on chest x-ray. Lack of ventilation study results in decreased specificity and sensitivity or possible emboli. Findings suspicious for low to an indeterminate probability of PE.
Suggest to continue the patient on Lovenox and consider Eliquis for a low to intermediate probability of pulmonary embolism. Patient has a prior history of venous thromboembolism but does not want to undergo CT angiogram secondary to contrast allergy even after premedication. Inconclusive studies high risk for PE
Seem like the provider decided to threat as if the patient as PE because CTA cannot be performed. Would you query to clarify if PE is ruled in? or just consider treatment as prophylactic? or no query is needed will code PE?