Wiki hospital visits

[sky]

"known to us.
Rt. BKA looks good.

Known severe P.A.D.
Previous left 3rd toe amputation--healed.
has dry gangrene L. lateral Hallux.
Charcot foot

Will discuss with Dr. "


this is what my doctor dictates for all of his progress notes for his hospital visits. what would you code this as? does he need to add more? just want to know how to approach him with this.

 

[cjhalk@yahoo.com]

I would first crumple up his note and throw it at him and ask him, ?WTF dude!!?
Here are the elements I see.
CC:
Gangrene
Charcot foot

History:
Known Severe PAD
Toe amputation
And above the knee amputation ?looks good.?

There is no exam.

There is no medical decision making above a brief. (I really don?t think ?will discuss w/ dr? is a valid MDM. Although will discuss with dr is a decision.

I do not think that 99231 is not reached in this case and would be coded as a 99499.

I would show him/her the cost of a 99231 vs a 99499. And advise this is what his/her documentation is providing. But if he/she is doing this all the time, I would start to show money. IF that doesn?t work, I would start giving 99499?s a crossed the board for dictation like this.