# consult level/HPI ?



## bwerner (Jul 21, 2009)

My surgeon dictated a consult on a patient that was sent to him because he had a positive hemoccult. He hits the points everywhere in his dictation except in his HPI (I think). 

The man isn't presenting with a current illness.

This is his HPI
"He was sent for consultation and consideration of colonoscopy. The patient in general states that he is feeling well. He tends to have one to two bowel movements a day. He denies any bright red blood per rectum or melanotic stools that he has noticed. In addition he denies any diarrhea or constipation. No alteration in his bowel habits. No weight loss. No change in appetite. He denies any FH of colon cancer. He denies any prior colonoscopy or known history of colities. He does have a history of hypercholesterolemia that is being managed medically."

He needs 4 elements or status of 3 chronic problems. I believe that these are more of a ROS than any elements. What do you think, should they be considered elements and if so, which do they fall under.


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## ARCPC9491 (Jul 21, 2009)

Well, if the man had a positive hemoccult ... that should be dictated somewhere ... primarily for the CC, thus resulting in the consult for colonoscopy consideration ...

something like: colonoscopy consideration *b/c of positive hemoccult*
but I guess for now the CC can be colonoscopy consideration

I would use *associated signs/symptoms *- denies bright red blood per rectum and *timing *- 2 bowel movements in 24 hour period. 

ROS, 1 GI, 1 Cons

2/3 PFSH 

add it all up ... and your history level is *Expanded Problem Focused*

What do you think?


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## bwerner (Jul 21, 2009)

I'm sorry... he does state in the first sentence that he is here because of the positive hemoccult. 

He had marked a level 4 consult, which I'm not really agreeing with. The only thing that I find he isn't making it in, is in the HPI and the four elements that he needs. Do you think what he dictated even though all signs and symptoms are negative that they should count as elements. I feel it is a 99242 because he didn't hit the four elements. 

He goes on and hits his PFSH and lots of ROS, do you still think it fall under 99242?


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## ARCPC9491 (Jul 21, 2009)

If he had documented a little more thorough in his HPI, 2 more elements, and did a 10 point ROS, he would have a complete history.

I agree with 99242 - assuming the exam and MDM are documented appropriately as well.


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## bwerner (Jul 21, 2009)

Thank you!


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## LLovett (Jul 21, 2009)

This doesn't really sound like a consult to me, it sounds like a transfer of care. "He was sent for consultation and consideration of colonoscopy" consideration of colonoscopy doesn't sound like the primary care is asking for an opinion or advice. It sounds like they are asking for the surgeon to treat the problem.

Just my opinion,

Laura, CPC


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## bwerner (Jul 21, 2009)

OH.....Don't even get me started about this subject. I totally agree that these arn't consults but we had a Dr. come ( Dr. Clouse w/ Optimal Coder)and speak to us and our physicans about getting higher levels and how to document and I went rounds with this speaker about consults and I have no one to back me up on this subject so I am just going with it. I'm very frusterated, he made consults sound like they are black and white but as we all know that is not true.


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## FTessaBartels (Jul 23, 2009)

*How to get 4 elements of HPI*

I'm not going to address whether this is a consult vs new patient ...

You are right that the current documentation does NOT have 4 elements. I concur with AR that you have 2 elements (associated signs and timing).

Now, *if *your physician had also documented:  "Positive hemoccult as result of routine physical exam  done dd/mm/yy" ... you'd have *context* and *duration*.

If he had had any mention of whether the patient was on aspirin therapy that might be a *modifying factor*. 

F Tessa Bartels, CPC, CEMC


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