Conference Review 2-15-17 ETOH/Nutrition and Billing/coding

Thank you to Maggie Krebs, MD for making these conference reviews!

EtOH and Nutrition

Review pathophysiology, diagnosis and treatment alcohol-related nutrition deficiencies.

  • Alcoholics are at risk for many nutritional deficiencies due to decreased nutrient intake via diet, decreased absorption and decreased hepatic storage.
  • Classically at risk for B12, folate, thiamine deficiency
  • B12 deficiency à megaloblastic anemia
  • Thiamine deficiency à Wernicke encephalopathy
  • Alcoholics also have decreased absorption of vitamins K, A, D, E and are also at risk for hypoK, hypomag, hypoCa
  • Diagnosis – obtain serum B12, folate, thiamine
  • May obtain serum levels but probably low yield especially in acutely drunk binge-drinkers
  • Classically, treatment in the ED is a banana bag but again, probably low yield in binge-drinkers who are otherwise healthy
  • Thiamine deficiency treatment 100 mg daily

Review pathophysiology, diagnosis and treatment of Wernicke Encephalopathy and Korsakoff Syndrome.

  • Wernicke Encephalopathy thiamine deficiency causing AMS, ocular dysfunction, ataxia
  • Korsakoff syndrome – memory impairment and confabulation
  • Thiamine is a cofactor in the Krebs cycle, deficiency leads to decrease in enzyme activity à lactate accumulation in the brain and serum à biochemical lesions can be seen in many different parts of the brain. Petechial hemorrhage can be seen in mammillary bodies
  • Treatment 500 mg IV TID x3 days, then 250 mg IV/IM daily
  • For one time dose of dextrose/glucose, do not need to worry about administering thiamine first

Review pathophysiology, diagnosis and treatment of ethanol withdrawal.

  • Pathophsyiology: Chornic EtOH use causes down-regulation of GABA receptors (inhibitory) and upregulation of NDMA receptors (excitatory). Withdrawal à inadequate activity of inhibitory receptors and excessive activity of excitatory receptors à hallucinations, seizures, hyperadrenergic state
  • Diagnosis: hypertension, tachycardia, tremors, diaphoresis, vomiting, headache, hallucinations, seizures (utilized in CIWA; downfall is scores can be intentionally manipulated via subjective complaints to get benzos)
  • Treatment benzos (Ativan, Valium, longer acting Librium), phenobarbital
  • Can consider precedex
  • Refractory seizures à intubation, propofol




Review the basics of EM documentation focusing on how to document a level 5 note.

  • History of present illness – need 4 elements from the following: location, quality, duration, severity, timing, context modifying factors, associated signs and symptoms (use CODIERS or OPQRST)
  • Need 2/3: past medical, family and social history

Focus on the scoring components of the MDM section and understand what elements to focus documentation time on

  • 2/3 categories (problems, data, risk) need to be high or extensive to bill as a level 5

Understand how an observation stay is billed and the importance of switching a patient to observation status as soon as possible

  • Requires a stay of at least 8 hours to bill as obs(expected less than 48h)
  • Decreased door to dispo times
  • If admission to obs order placed before mignight, can be difference between a same day or 2 days obs charge (2 day obs charge more than 1 day)

Learn to document clinical impression per ICD-10 guidelines and review general EM code reimbursement levels.

  • precise anatomic location is important (including R vs L)
  • Where: geographic location important
  • Why: Circumstances/activity surrounding
  • How: injury related to work, military, altercation etc.