Wiki Intial Hospital Visit

[AshleyMartin]

This is a consult report one of my physician's dictated. Would you bill this a 99221 or 99222?

Consult Re: Hypotension and tachycardia

HPI: Patient is a 52 y/o m with history of quadriplegia s/p motor vehicle accident. Patient is well known to us previously seen by Dr. R. Patient has history of tracheostomy and is chronically bedbound. Has history of complicated pacemaker placement for bradycardia and high degree AV block. He is admitted to the intensive care unit for hypotension and sepsis. Family is not at bedside currently. Most of this history is obtained per the medical record.

ROS: Unable to obtain

Allergies: Albuterol, Ativan and sulfa.

PMHX: Thyroid disorder, history of DVT, history of anasarca

PSHX: History of IVC filter placement, pacemaker placement

SOCHX: No tobacco, alcohol or illicits

FAMHX: Non contributory

(Vital signs from the last 24 hours are here, taken from EMR)

general: no apparent distress
neck: tracheostomy
cv: tachycardic S1-S2
chest: coarse breath sounds anteriorly
abd: deferred
ext: diffuse edema

(Last 4 charted lab values are here, taken from EMR)

Assessment:
52 y/o male, history of quadroplegia s/p motor vehicle accident, s/p tracheostomy, remote pacemaker placement for bradycardia/AV block. Hisory of multiple admissions for recurrent infections. Admitted to the intensive care unit for likely sepsis.

Plan:
1. Hypotension - continue supportive care with pressors
2. Sepsis - Ifectious Disease following; currently on antibiotics
3. Quadriplegia status post motor vehicle accident
4. Tachycardia - currently in normal sinus rhythm and secondary response to #1-2
5. History of bradycardia and AV block status post pacemaker - device was interrogated today and is functioning well.

Prognosis guarded.

 

[btadlock1]

This is a consult report one of my physician's dictated. Would you bill this a 99221 or 99222?

Consult Re: Hypotension and tachycardia

HPI: Patient is a 52 y/o m with history of quadriplegia s/p motor vehicle accident. Patient is well known to us previously seen by Dr. R. Patient has history of tracheostomy and is chronically bedbound. Has history of complicated pacemaker placement for bradycardia and high degree AV block. He is admitted to the intensive care unit for hypotension and sepsis. Family is not at bedside currently. Most of this history is obtained per the medical record.

ROS: Unable to obtain

Allergies: Albuterol, Ativan and sulfa.

PMHX: Thyroid disorder, history of DVT, history of anasarca

PSHX: History of IVC filter placement, pacemaker placement

SOCHX: No tobacco, alcohol or illicits

FAMHX: Non contributory

(Vital signs from the last 24 hours are here, taken from EMR)

general: no apparent distress
neck: tracheostomy
cv: tachycardic S1-S2
chest: coarse breath sounds anteriorly
abd: deferred
ext: diffuse edema

(Last 4 charted lab values are here, taken from EMR)

Assessment:
52 y/o male, history of quadroplegia s/p motor vehicle accident, s/p tracheostomy, remote pacemaker placement for bradycardia/AV block. Hisory of multiple admissions for recurrent infections. Admitted to the intensive care unit for likely sepsis.

Plan:
1. Hypotension - continue supportive care with pressors
2. Sepsis - Ifectious Disease following; currently on antibiotics
3. Quadriplegia status post motor vehicle accident
4. Tachycardia - currently in normal sinus rhythm and secondary response to #1-2
5. History of bradycardia and AV block status post pacemaker - device was interrogated today and is functioning well.

Prognosis guarded.

99221 - you need a comprehensive exam to bill 99222, and I only count 5 organ systems, or 6 bullets (assuming that there were at least 3/7 required vitals taken). By 95 guidelines, it's detailed, and by 97 guidelines, it's barely EPF. The provider should take more care in documenting their exam, because the history, MDM, and medical necessity for 99222 (or even 99223) were all there, but without all 3 components being met/exceeded on the initial visit, he can't bill as high of a visit as this probably warranted. You can only assign the level of the lowest-scoring component on E/M's that require 3/3. Hope that helps!