NESmith
Expert
Please help me with this hospital visit, there is a slight disagreement on how this should be coded.
HPI:
The patient was admitted through the emergency room last night. She is 97 years old and is in an assisted living facility.She began having abdominal pain approximately 2 days ago. She complains of some pain mainly in the epigastrium and right upper quadrant. She has had some nausea but very little vomiting. She has had no fever, chills or jaundice.
Past Medical History: Status post bilateral knee arthroplasty, history of hypertension, history of uterine cancer status post hysterectomy, status post appendectomy, hisotry of hyperthyroidism, history of diverticulitis.
Social Hsitory: The patient is in attendance by her son-in-law. Her daughter is deceased. She is very active but requires a walker at home.
Family History: Noncontributory
Physical Exam:
General: the patient awake, alert, oriented.
Vital Signs: Temperature is 98, pulse 70, respirations 18, blood pressure 130/90.
HEENT: Nonicteric
Neck: Supple
Chest: Clear
Heart: Regular rate and rhythm. No murmur or gallop.
Abdomen: Soft. There is a lower midline abdominal incision present and a right lower quadrant incision present.
Extremities: There is slight edema at the ankles. There is evidence of previos knee arthroplasty. Dorsalis pedis and posterior pulses are intact.
Central nervous System: no focal neurologic abnormalities.
Imaging Study: Ultrasound of the abdomen demonstrates cholelithiasis with a thickened gallbladder wall.
Laboratory Data:
White blood cell count is 12,000, hemoglobin is 11.9. Liver function tests show slightly elevated alkaline phosphatase but normal bilirubin and normal pancreatic enzymes.
Diagnostic Impression: Acute cholecystitis. I discussed laproscopic cholecystectomy with the patient and her son-in-law today. The risk and potential hazards of surgery in this elderly female have been discussed at length.
Plan: Lap Chole, possible open cholecystectomy.
Provider coding 99223-57
Please give your opinion. Thank You.
HPI:
The patient was admitted through the emergency room last night. She is 97 years old and is in an assisted living facility.She began having abdominal pain approximately 2 days ago. She complains of some pain mainly in the epigastrium and right upper quadrant. She has had some nausea but very little vomiting. She has had no fever, chills or jaundice.
Past Medical History: Status post bilateral knee arthroplasty, history of hypertension, history of uterine cancer status post hysterectomy, status post appendectomy, hisotry of hyperthyroidism, history of diverticulitis.
Social Hsitory: The patient is in attendance by her son-in-law. Her daughter is deceased. She is very active but requires a walker at home.
Family History: Noncontributory
Physical Exam:
General: the patient awake, alert, oriented.
Vital Signs: Temperature is 98, pulse 70, respirations 18, blood pressure 130/90.
HEENT: Nonicteric
Neck: Supple
Chest: Clear
Heart: Regular rate and rhythm. No murmur or gallop.
Abdomen: Soft. There is a lower midline abdominal incision present and a right lower quadrant incision present.
Extremities: There is slight edema at the ankles. There is evidence of previos knee arthroplasty. Dorsalis pedis and posterior pulses are intact.
Central nervous System: no focal neurologic abnormalities.
Imaging Study: Ultrasound of the abdomen demonstrates cholelithiasis with a thickened gallbladder wall.
Laboratory Data:
White blood cell count is 12,000, hemoglobin is 11.9. Liver function tests show slightly elevated alkaline phosphatase but normal bilirubin and normal pancreatic enzymes.
Diagnostic Impression: Acute cholecystitis. I discussed laproscopic cholecystectomy with the patient and her son-in-law today. The risk and potential hazards of surgery in this elderly female have been discussed at length.
Plan: Lap Chole, possible open cholecystectomy.
Provider coding 99223-57
Please give your opinion. Thank You.