Below is a note that one of my physicians wrote in a patient's chart. I reviewed it and found that I was coding a 99232. Can someone review it and let me know what you think?
Called to see patient f: At the request of Dr. Seroma
She is from bay City and her cardiologist is Dr. Hanna.
The reason the consult is requested is atrial fibrillation and questionable hypertension
Atrial fibrillation and (?) hypertension.
This patient gives a history of having a single chamber implanted in the year 2000.
Has been i atrial fibrillation for years.
Has a history of DVT and when placed on coumadin had profuse GI bleed.
As an IVC filter.
Subsequently in the year 2003 had endoluminal repair of an abdominal aortic aneurysm,..
According to the nurse she has NO active cardiac issues. She has a Blood pressure of 116/63.
She is in a paced rhythm at a heart of 70 bpm with underlying atrial flutter/fibrillation.
Is entirely asymptomatic from cardiac standpoint.
Was admitted to the hospital for complications of a recent colostomy.
Denies any cardiac symptoms. No chest pain, shortness of breath Or plapitations.
On examination:
She is perfectly comfortable.
BP 116/63 Paced rhtyhm at 70 bpm.
JVP not elevated, no significant carotid bruits.
Pacemaker in the left pectoral area.
Regular cardiac rhythm.
No audible murmurs, gallops or rubs.
Tender abdomen from recent surgical procedure.
Peripheral pulses are present. There is no edema.
In Summary: this patient has chronic atrial fibrillation. A permanent VVI pacemaker and a history of endoluminal aortic aneurysm repair.
She does not need any cardiac treatment , She bleeds every time coumadin is utilized and because of the recent abdominal surgery the use of Pradaxa, xarelto or eliquis is contraindicated.
No specific Cardiac therapy is needed at this point.
Called to see patient f: At the request of Dr. Seroma
She is from bay City and her cardiologist is Dr. Hanna.
The reason the consult is requested is atrial fibrillation and questionable hypertension
Atrial fibrillation and (?) hypertension.
This patient gives a history of having a single chamber implanted in the year 2000.
Has been i atrial fibrillation for years.
Has a history of DVT and when placed on coumadin had profuse GI bleed.
As an IVC filter.
Subsequently in the year 2003 had endoluminal repair of an abdominal aortic aneurysm,..
According to the nurse she has NO active cardiac issues. She has a Blood pressure of 116/63.
She is in a paced rhythm at a heart of 70 bpm with underlying atrial flutter/fibrillation.
Is entirely asymptomatic from cardiac standpoint.
Was admitted to the hospital for complications of a recent colostomy.
Denies any cardiac symptoms. No chest pain, shortness of breath Or plapitations.
On examination:
She is perfectly comfortable.
BP 116/63 Paced rhtyhm at 70 bpm.
JVP not elevated, no significant carotid bruits.
Pacemaker in the left pectoral area.
Regular cardiac rhythm.
No audible murmurs, gallops or rubs.
Tender abdomen from recent surgical procedure.
Peripheral pulses are present. There is no edema.
In Summary: this patient has chronic atrial fibrillation. A permanent VVI pacemaker and a history of endoluminal aortic aneurysm repair.
She does not need any cardiac treatment , She bleeds every time coumadin is utilized and because of the recent abdominal surgery the use of Pradaxa, xarelto or eliquis is contraindicated.
No specific Cardiac therapy is needed at this point.