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.
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.
