Trendale
Guest
How would you code this? The physcian wants to code a level 4.
History OF PRESENT ILLNESS: This is a 51-year-old homeless male
admitted through the emergency room last night with generalized
weakness, alcohol intoxication, shortness of breath, cough, low-grade
hemoptysis, and right lower lobe infiltrate. Patient has a history of
heavy tobacco abuse and alcohol abuse. He was hospitalized here in
December, January 2009. At that time he had some patchy upper lobe
infiltrates and bilateral pleural effusions on chest CT scan, treated
for bronchitis exacerbation, and resolved. He was recently in shelter
and had an episode of seizures. He states he fell, hit his head, lost
consciousness, and was seen in the emergency room somewhere where he
had some staples put in. He had no further seizures, but has
obviously been drinking and presented this time with alcohol
intoxication. He has had increased cough, some yellow sputum
production, some increased shortness of breath other than baseline.
He smokes. He has about a 30 to 40-pack-year smoking history,
continues to smoke a pack of cigarettes daily and drinks heavily. He
reports no known history of tuberculosis in the past. No intravenous
drug use and no history of HIV exposure by his history. He denies any
other significant environmental exposure history.
PAST MEDICAL HISTORY: Has a past history significant for hypertension
and history of depression.
ALLERGIES: Denies any drug allergies.
SOCIAL HISTORY: Heavy smoker as mentioned. He worked as a welder in
the past and had some exposure possibly in that environment. He has
been homeless for about 7 years.
FAMILY HISTORY: Significant for coronary artery disease, ASCVD.
REVIEW OF SYSTEMS: Noncontributory except what is listed.
PHYSICAL EXAMINATION: Reveals a well-developed male. He is unkempt,
in no acute distress. He is pleasant. Temperature last evening was
100.9, currently afebrile. Blood pressure 129/70, pulse is 100 and
regular, respiratory rate is 18, nonlabored. HEENT reveals poor
dentition. The oropharynx without lesions. No exudates seen in the
posterior pharynx. NECK: Supple, trachea is midline, no adenopathy
appreciated in the supraclavicular or cervical region. CARDIAC:
Regular rhythm, normal S1, S2, no gallop, no JVD. LUNGS: Reveal
slightly decreased breath sounds. Minimal right basilar crackles. No
wheezes heard. Normal resonance to percussion. Good air entry in the
upper lung zones bilaterally. No rhonchi. ABDOMEN: Soft and
nondistended, nontender, no organomegaly detected. GENITOURINARY AND
RECTAL: Deferred. EXTREMITIES: Reveal no peripheral edema,
clubbing, or cyanosis. No palpable cords. NEUROLOGIC: Grossly
nonfocal.
LABORATORY DATA: Sodium 143, potassium 4.1, bicarbonate 33, BUN 4,
creatinine 0.8. Liver function studies normal. Ethanol level on
admission was 390. Dilantin level less than 1. Theophylline level
less than 2. Tylenol level negative. Troponin 0.01. White count
7300, hemoglobin 14.4, platelet count 123,000. Sputum culture thus
far negative. Blood cultures negative today times 2. Chest x-ray
shows right basilar infiltrate portable film. No cavitary infiltrate
is seen. No significant effusion noted. Heart size appears normal.
CT of the chest from January 2, 2009 did show bilateral pleural
effusions, moderate in size, right greater than left, some compressive
atelectasis and subtle vague reticular nodular infiltrate in the left
upper lobe greater than the right. Borderline enlarged lymph nodes
evident.
IMPRESSION:
1 Heavy tobacco abuse.
2 COPD (chronic obstructive pulmonary disease), chronic bronchitis.
3 Right lower lobe pneumonia suggested.
4 Low-grade hemoptysis likely secondary to above, rule out TB
(tuberculosis) given the patient's social status and hemoptysis.
5 Reported recent weight loss.
6 Alcohol abuse with intoxication on admission.
7 Homeless status.
8 History of seizure disorder with subtherapeutic Dilantin level.
9 History of depression in the past.
RECOMMENDATIONS: Will await sputum for AFB stain and culture. Place
PPD skin test. PA and lateral chest x-ray as well as follow up chest
CT scan in light of his previous adenopathy. Given his weight loss,
will go ahead with T-cell profile studies. Smoking cessation was
advised. Unfortunately, his social status and homeless status,
inability to obtain insurance and medications greatly impair his
ability for ongoing self-care and medical care.
I believe the statement for the ROS is invalid. According to the guidelines at least 1 pertinent ROS should be listed following the statement," the remainder of the ROS is negative and noncontributory to the present illness, or just list all 10 ROS, otherwise, 2-9 is a detailed level 3, but regarding the statement documentd for the ROS, I am not even sure how to choose a level based on that. I am having this issue very often with other physcians, where the ROS is taken likely, and they are expecting to get a level 5. This is a prime example. another example, they may check 3-4 systems, hit a high in the other components and expects a level 5.
Please let me know your thoughts and recomendations. Thanks in advance!
History OF PRESENT ILLNESS: This is a 51-year-old homeless male
admitted through the emergency room last night with generalized
weakness, alcohol intoxication, shortness of breath, cough, low-grade
hemoptysis, and right lower lobe infiltrate. Patient has a history of
heavy tobacco abuse and alcohol abuse. He was hospitalized here in
December, January 2009. At that time he had some patchy upper lobe
infiltrates and bilateral pleural effusions on chest CT scan, treated
for bronchitis exacerbation, and resolved. He was recently in shelter
and had an episode of seizures. He states he fell, hit his head, lost
consciousness, and was seen in the emergency room somewhere where he
had some staples put in. He had no further seizures, but has
obviously been drinking and presented this time with alcohol
intoxication. He has had increased cough, some yellow sputum
production, some increased shortness of breath other than baseline.
He smokes. He has about a 30 to 40-pack-year smoking history,
continues to smoke a pack of cigarettes daily and drinks heavily. He
reports no known history of tuberculosis in the past. No intravenous
drug use and no history of HIV exposure by his history. He denies any
other significant environmental exposure history.
PAST MEDICAL HISTORY: Has a past history significant for hypertension
and history of depression.
ALLERGIES: Denies any drug allergies.
SOCIAL HISTORY: Heavy smoker as mentioned. He worked as a welder in
the past and had some exposure possibly in that environment. He has
been homeless for about 7 years.
FAMILY HISTORY: Significant for coronary artery disease, ASCVD.
REVIEW OF SYSTEMS: Noncontributory except what is listed.
PHYSICAL EXAMINATION: Reveals a well-developed male. He is unkempt,
in no acute distress. He is pleasant. Temperature last evening was
100.9, currently afebrile. Blood pressure 129/70, pulse is 100 and
regular, respiratory rate is 18, nonlabored. HEENT reveals poor
dentition. The oropharynx without lesions. No exudates seen in the
posterior pharynx. NECK: Supple, trachea is midline, no adenopathy
appreciated in the supraclavicular or cervical region. CARDIAC:
Regular rhythm, normal S1, S2, no gallop, no JVD. LUNGS: Reveal
slightly decreased breath sounds. Minimal right basilar crackles. No
wheezes heard. Normal resonance to percussion. Good air entry in the
upper lung zones bilaterally. No rhonchi. ABDOMEN: Soft and
nondistended, nontender, no organomegaly detected. GENITOURINARY AND
RECTAL: Deferred. EXTREMITIES: Reveal no peripheral edema,
clubbing, or cyanosis. No palpable cords. NEUROLOGIC: Grossly
nonfocal.
LABORATORY DATA: Sodium 143, potassium 4.1, bicarbonate 33, BUN 4,
creatinine 0.8. Liver function studies normal. Ethanol level on
admission was 390. Dilantin level less than 1. Theophylline level
less than 2. Tylenol level negative. Troponin 0.01. White count
7300, hemoglobin 14.4, platelet count 123,000. Sputum culture thus
far negative. Blood cultures negative today times 2. Chest x-ray
shows right basilar infiltrate portable film. No cavitary infiltrate
is seen. No significant effusion noted. Heart size appears normal.
CT of the chest from January 2, 2009 did show bilateral pleural
effusions, moderate in size, right greater than left, some compressive
atelectasis and subtle vague reticular nodular infiltrate in the left
upper lobe greater than the right. Borderline enlarged lymph nodes
evident.
IMPRESSION:
1 Heavy tobacco abuse.
2 COPD (chronic obstructive pulmonary disease), chronic bronchitis.
3 Right lower lobe pneumonia suggested.
4 Low-grade hemoptysis likely secondary to above, rule out TB
(tuberculosis) given the patient's social status and hemoptysis.
5 Reported recent weight loss.
6 Alcohol abuse with intoxication on admission.
7 Homeless status.
8 History of seizure disorder with subtherapeutic Dilantin level.
9 History of depression in the past.
RECOMMENDATIONS: Will await sputum for AFB stain and culture. Place
PPD skin test. PA and lateral chest x-ray as well as follow up chest
CT scan in light of his previous adenopathy. Given his weight loss,
will go ahead with T-cell profile studies. Smoking cessation was
advised. Unfortunately, his social status and homeless status,
inability to obtain insurance and medications greatly impair his
ability for ongoing self-care and medical care.
I believe the statement for the ROS is invalid. According to the guidelines at least 1 pertinent ROS should be listed following the statement," the remainder of the ROS is negative and noncontributory to the present illness, or just list all 10 ROS, otherwise, 2-9 is a detailed level 3, but regarding the statement documentd for the ROS, I am not even sure how to choose a level based on that. I am having this issue very often with other physcians, where the ROS is taken likely, and they are expecting to get a level 5. This is a prime example. another example, they may check 3-4 systems, hit a high in the other components and expects a level 5.
Please let me know your thoughts and recomendations. Thanks in advance!