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A 60-year-old female with severe rheumatoid arthritis returns for an infliximab infusion. She is currently on methotrexate and prednisone. The patient reports no active infection. She reports the she has tenderness in her right fingers and right knee. The patient’s history is expanded problem focused.
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Explore This IssueDecember 2012
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The patient’s weight is 169 pounds, her height is 5 feet 7 inches, and her temperature is 98.7 degrees. The patient is well groomed and appears to be in good spirits. Her heart’s rate and rhythm are within normal limits. Her right hand and right knee have slight tenderness and some swelling. There are no rashes on her head or neck, torso, right upper or lower extremities, or her left upper or lower extremities.
The infusion is started at 1:30 PM. After 35 minutes and 200 mg of infliximab, the patient has an adverse reaction. The infusion is stopped. The patient’s IV is flushed with saline for 32 minutes and diphenhydramine is pushed into the IV to counteract the adverse reaction. The infusion is discontinued and the patient is monitored for 30 minutes. The patient is scheduled for a follow-up visit in a week.
- What was the level of medical decision making?
- How is the infliximab infusion coded?
- How is the diphenhydramine push coded?
- How is the saline infusion coded?
- How many units would be coded for the infliximab?