# How would you code this note?  Levels??



## CJames72 (Jan 29, 2013)

I would really appreciate getting some second opinions on this note using susequent hospital care codes; NO consult codes. Please break down the History, Exam, and MDM levels too.  I would like to get a 2nd opinion.  I have 99232 with EPF/EPF/MOD.

Thanks so much.

Patient consulted by ER physician for left intertrochanteric hip fracture.
CC: Left hip fracture
HPI: The patient is 80 year CVA, dementia, osteoporosis, hypothyroidism and arthritis.  He was walking at home without his walker and fell from standing.  The patient was unable to bear weight and had pain and tenderness.  There was no loss of consciousness.  He was brought to ER where left intertrochanteric hip fracture was noted.
PAST MEDICAL:  History of CVA, dementia, hypothyroidism, osteoporosis, arthritis, and GERD.
MEDS: Donepezil, Levothyroxine, Nexium
ALLERGIES: None
SOCIAL HISTORY: Patient lives at home alone.
FAMILY HISTORY: Noncontributory
ROS:  MUSCULOSKELETAL:  The patient has pain in left hip area.  NEUROLOGIC:  Denies numbness and vertigo.  SKIN:  negative.  CARDIOVASCULAR:  Negative for chest pain.  RESPIRATORY:  Negative for Shortness of breath.  HEENT:  Negative for neck pain.  
PHYSICAL EXAM:  GENERAL:  Elderly male, lying in bed, appears comfortable except for pain when moving left leg.  HEENT:  Normocephalic.  NECK:  No jugular distention.  LUNGS:  Clear.  HEART:  Regular rhythm.  ABDOMEN:  Soft, nontender.  EXTREMITIES:  Left lower extremity, foot is warm, very thread dorsalis pedis pulse.  Gross sensation is intact in the foot.  He can mover his foot. The calf is supple.  Again, xrays show left intertrochanteric hip fracture.  DIAGNOSIS:  Left intertrochanteric hip fracture.  ASSESSMENT AND PLAN:  Risks of surgery explained and the high mortality rate post op in first year after hip fractures.  Other risks including hardware failure, stroke, and MI.  He understood and was agreeable.  The patient is to be cleared for surgery and will be able to do ORIF of left hip.


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## nyarborough (Jan 30, 2013)

*Inpatient E & M level on 2nd opinion note*

I agree with you as far as the level my components are as follows:

History - Detailed 
Exam - Expanded problem focused
MDM - Moderate

so I agree with your selection 99232 - 

but I want to give it a 99233 - but the documentation doesnt support it.

I say that because by it being a 2nd opnion, the provider (hopefully) reviewed old medical records regarding the CC.  Given the patient's history of CVA, osetoporosis, arthritis, and age - I feel as though there were other factors that the provider had to have considered (other than an x-ray) before clearing this patient for surgery.  Personally, I feel that there a lot of MDM left out that could have supported a subsequent lvl 3 visit - or maybe I just have too much confidence in the medical care given by this provider -


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## CJames72 (Jan 30, 2013)

*Detailed History*

Thank you for the reply and input.  Which elements did you use to get a detailed history?


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## MikeEnos (Jan 30, 2013)

HPI 
Context - Fell
Severity - unable to bear weight
Associated Signs & Symptoms - pain and tenderness, no LOC
Location - left intertrochanteric hip
________
extended HPI

ROS
Musculoskeletal, Neurologic, Skin
_________
extended ROS

PFSH
Medical (CVA) Social (lives at home) Family (noncontributory)
_______
2 or 3 PFSH depending on if your carrier accepts noncontributory 

So 
Extended HPI
Extended ROS
2 or 3 PFSH for a new patient
____________
Detailed History


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## MikeEnos (Jan 30, 2013)

For what it's worth, I also got a Detailed exam:
Body Areas:
-Head
-Neck

Organ Systems:
-Constitutional
-Respiratory
-Cardiovascular
-Gastrointestinal
-Neurologic
-Musculoskeletal

I agree with you on the Moderate MDM


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## nyarborough (Jan 30, 2013)

CJames72 said:


> Thank you for the reply and input.  Which elements did you use to get a detailed history?



Sorry just getting back on the board . . . got side tracked today . . . I agree with the coder that responded after me

Fell
Hip
Pain and tenderness
unable to bear weight


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## sullivak (Feb 4, 2013)

I agree with Mike Enos that this would be a Detailed exam as well. DET/DET/MOD

GENERAL: Elderly male, lying in bed, appears comfortable except for pain when moving left leg. [CONST]
HEENT: Normocephalic. [HEAD] NECK: No jugular distention. [NECK] 
LUNGS: Clear. [RESPIRATORY]
HEART: Regular rhythm. [CARDIOVASC]
ABDOMEN: Soft, nontender. [ABDOMEN]
EXTREMITIES: Left lower extremity, foot is warm [MUSC], very thread dorsalis pedis pulse [CV]. Gross sensation is intact in the foot [neuro]. He can mover his foot. The calf is supple. [musculoskeletal] Again, xrays show left intertrochanteric hip fracture. 

8 body area/systems


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