I have questions regarding the following two cases. If anyone wants to offer their expertise I would greatly appreciate it.
Case#1
Pt has been admitted to elevate her ankle. She has a severe pilon fracture with associated soft tissue swelling. She has a splint in lace.
EXAM: Oriented and alert. Affect and mood good. VITALS: Temp 98.0, BP 125/70, Pulse 65. LAB: INR 1.32. PLAN: There is still swelling but the skin is wrinkling. She should be clear for surgery in the morning. She will be n.p.o and ORIF in morning.
I came up with EPF/EPF/MOD. Do you agreed with moderate for MDM? Or would low be more accurate?
Case#2
Pt had a splint removed from her ankle, which was reviewed today. Still swelling present. She is not ready for surgery. EXAM: VITALS: Temp, 97.6, pulse 75, BP 135/74. LAB: Hematocrite is 34.2 and INR is 1.21. The skin does not wrinkle but is intact. TREATMENT: Pt needs to continue elevating and be n.p.o.
I came up with no history since the doctor states the location in relation to the exam rather than history. For exam I have EPF and SF MDM. It's mainly the History portion I am questioning.
It is similar to this case in which the note stated "The pt was seen today. His knee was inspecte. There is inflamation on the knee. He can flex. Pt to continue sitting up." On this one I initially coded PF history for location but was told that was incorrect since the knee was only mentioned in regards to the exam. So I am confused. Other coders' input is GREATLY appreciated.
Thank you.
Case#1
Pt has been admitted to elevate her ankle. She has a severe pilon fracture with associated soft tissue swelling. She has a splint in lace.
EXAM: Oriented and alert. Affect and mood good. VITALS: Temp 98.0, BP 125/70, Pulse 65. LAB: INR 1.32. PLAN: There is still swelling but the skin is wrinkling. She should be clear for surgery in the morning. She will be n.p.o and ORIF in morning.
I came up with EPF/EPF/MOD. Do you agreed with moderate for MDM? Or would low be more accurate?
Case#2
Pt had a splint removed from her ankle, which was reviewed today. Still swelling present. She is not ready for surgery. EXAM: VITALS: Temp, 97.6, pulse 75, BP 135/74. LAB: Hematocrite is 34.2 and INR is 1.21. The skin does not wrinkle but is intact. TREATMENT: Pt needs to continue elevating and be n.p.o.
I came up with no history since the doctor states the location in relation to the exam rather than history. For exam I have EPF and SF MDM. It's mainly the History portion I am questioning.
It is similar to this case in which the note stated "The pt was seen today. His knee was inspecte. There is inflamation on the knee. He can flex. Pt to continue sitting up." On this one I initially coded PF history for location but was told that was incorrect since the knee was only mentioned in regards to the exam. So I am confused. Other coders' input is GREATLY appreciated.
Thank you.