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The doctor billed 99223 for the following. Insurance requested records and downcoded. We agree with the insurance company that the service does not meet that level of service. The provider wants a second opinion from outside. Can I get someone to weigh in on this one and get your opinion? Your assistance is appreciated!
REASON FOR CONSULTATION:
Acute myocardial infarction.
HISTORY OF PRESENT ILLNESS
This is a 66 year old gentleman who came to the hospital with acute onset of retrosternal and left-sided chest pain associated with nausea. The patient had dynamic ST-T wave changes on EKG, hence, urgent Cardiology consultation was called by ER physician. The case was discussed with Dr._____. The patient had intermittent chest pain with ST changes, as well as occasional premature ventricular complex. the patient denied dizziness, palpitations or loss of consciousness. The patient does have a history of smoking.
PAST MEDICAL HISTORY
1. History of smoking.
2. Anxiety and Depression
3. Posttraumatic stress disorder.
The patient denies any previous history of coronary artery disease or cardiac arrhythmias.
SOCIAL HISTORY
the patient has a history of smoking 1 pack per day, occasional alcohol use. He denies recreational drug use. The patient has not been following up physicians on a regular basis. He has seen one physician one time over the last few months. Prior to that, he has not seen anybody for significant long time.
REVIEW OF SYSTEMS
GENERAL: The patient denies fevers, chills or malaise.
PULMONARY: Denies cough of hemoptysis.
CARDIOVASCULAR: As mentioned above.
GASTROINTESTINAL: Denies abdominal pain, diarrhea or constipation.
GENITOURINARY: Denies dysuria, pyuria or hematuria.
NEUROLOGICAL: Denies any focal weakness.
PSYCHIATRIC: As mentioned above with history of anxiety and depression.
ENDOCRINE: Denies thyroid disorder.
HEMATOLOGICAL: Denies easy bruising.
MUSCULOSKELETAL: Denies any joint pain at present.
Other review of systems is review and as mentioned above, otherwise negative.
A fourteen-point review of systems is assessed.
MEDICATIONS AT HOME:
Included:
1. Remeron
2. Xanax
3. Albuterol
4. Ibuprophen
5. __________
ALLERGIES
NO KNOWN DRUG ALLERGIES.
PHYSICAL EXAMINATION
VITAL SIGNS: Heart rate is 95 beats per minute, blood pressure 145/83 and temperature is 97.6.
HEENT: There is no jugular venous distention.
NECK: Supple.
LUNGS: Air entry is adequate bilaterally. There are a few rhonchi.
CARDIOVASCULAR: Regular S1 and S2. There is no S3 or S4 notes. No murmurs or rubs.
ABDOMEN: Soft and nontender.
EXTREMITIES: There is no pedal edema.
DIAGNOSTIC DATA
Electrocardiogram reveals sinus rhythm with anteroseptal myocardial infarction and ST depressions in lead II, III, aVF, as well as V4, V5 and V6.
LABORATORY VALUES
Noted with white count of 12.4 and hemoglobin is 17.2. Creatinine is 1.3. Troponin is 0.62. AFT is 29.__.
DIAGNOSTIC IMPRESSION
1. Acute non-ST elevation myocardial infarction with dynamic EKG changes and ST depressions.
2. History of smoking.
3. History of anxiety and depression.
4. Mild renal insufficiency.
RECOMMENDATIONS
The patient will be taken to cardiac catheterization lab in emergent fashion in view of his symptoms and EKG changes. The patient will have an echocardiogram performed. He has been started on aspirin and nitroglycerin therapy in the emergency room. The case was discussed with Dr._______. It was discussed at length with the patient, as well as the procedure and informed consent was obtained. Further management will depend on the patient's clinical course.
Thank you very much for asking me to participate in the patient. If you have any questions, do not hesitate to call.
Again, thanks for your help!
REASON FOR CONSULTATION:
Acute myocardial infarction.
HISTORY OF PRESENT ILLNESS
This is a 66 year old gentleman who came to the hospital with acute onset of retrosternal and left-sided chest pain associated with nausea. The patient had dynamic ST-T wave changes on EKG, hence, urgent Cardiology consultation was called by ER physician. The case was discussed with Dr._____. The patient had intermittent chest pain with ST changes, as well as occasional premature ventricular complex. the patient denied dizziness, palpitations or loss of consciousness. The patient does have a history of smoking.
PAST MEDICAL HISTORY
1. History of smoking.
2. Anxiety and Depression
3. Posttraumatic stress disorder.
The patient denies any previous history of coronary artery disease or cardiac arrhythmias.
SOCIAL HISTORY
the patient has a history of smoking 1 pack per day, occasional alcohol use. He denies recreational drug use. The patient has not been following up physicians on a regular basis. He has seen one physician one time over the last few months. Prior to that, he has not seen anybody for significant long time.
REVIEW OF SYSTEMS
GENERAL: The patient denies fevers, chills or malaise.
PULMONARY: Denies cough of hemoptysis.
CARDIOVASCULAR: As mentioned above.
GASTROINTESTINAL: Denies abdominal pain, diarrhea or constipation.
GENITOURINARY: Denies dysuria, pyuria or hematuria.
NEUROLOGICAL: Denies any focal weakness.
PSYCHIATRIC: As mentioned above with history of anxiety and depression.
ENDOCRINE: Denies thyroid disorder.
HEMATOLOGICAL: Denies easy bruising.
MUSCULOSKELETAL: Denies any joint pain at present.
Other review of systems is review and as mentioned above, otherwise negative.
A fourteen-point review of systems is assessed.
MEDICATIONS AT HOME:
Included:
1. Remeron
2. Xanax
3. Albuterol
4. Ibuprophen
5. __________
ALLERGIES
NO KNOWN DRUG ALLERGIES.
PHYSICAL EXAMINATION
VITAL SIGNS: Heart rate is 95 beats per minute, blood pressure 145/83 and temperature is 97.6.
HEENT: There is no jugular venous distention.
NECK: Supple.
LUNGS: Air entry is adequate bilaterally. There are a few rhonchi.
CARDIOVASCULAR: Regular S1 and S2. There is no S3 or S4 notes. No murmurs or rubs.
ABDOMEN: Soft and nontender.
EXTREMITIES: There is no pedal edema.
DIAGNOSTIC DATA
Electrocardiogram reveals sinus rhythm with anteroseptal myocardial infarction and ST depressions in lead II, III, aVF, as well as V4, V5 and V6.
LABORATORY VALUES
Noted with white count of 12.4 and hemoglobin is 17.2. Creatinine is 1.3. Troponin is 0.62. AFT is 29.__.
DIAGNOSTIC IMPRESSION
1. Acute non-ST elevation myocardial infarction with dynamic EKG changes and ST depressions.
2. History of smoking.
3. History of anxiety and depression.
4. Mild renal insufficiency.
RECOMMENDATIONS
The patient will be taken to cardiac catheterization lab in emergent fashion in view of his symptoms and EKG changes. The patient will have an echocardiogram performed. He has been started on aspirin and nitroglycerin therapy in the emergency room. The case was discussed with Dr._______. It was discussed at length with the patient, as well as the procedure and informed consent was obtained. Further management will depend on the patient's clinical course.
Thank you very much for asking me to participate in the patient. If you have any questions, do not hesitate to call.
Again, thanks for your help!