How would you code the following scenario? My physician wants to bill a 99212. I'm not very experienced with E/M auditing. Would you bill this as a 99214? Thanks!
Patient has stage III chronic kidney disease secondary to nephrosclerosis. He was admitted to the hospital in July for a urinary tract infection and acute renal failure attributed to Bactrim. At his last office visit he was having another episode of acute renal failure. His blood pressure was low at that time. Terazosin was discontinued and torsemide was decreased to 20 mg q.o.d. Since that time he feels very well but developed lower tract obstructive symptoms and placed on Flomax.
CURRENT MEDICATIONS:
1. Altace 10 mg b.i.d.
2. Amiodarone 200 mg q.d.
3. Coumadin sliding scale.
4. Coreg CR 40 mg q.d.
5. Torsemide 20 mg q.o.d.
6. Repliva q 3 days.
7. Flomax .4 mg q.o.d.
PHYSICAL EXAMINATION:
Alert and oriented x 3. No complaints of chest pain or shortness of air. Weight: 178. Blood pressure: 140/80. Pulse: 64. HEENT: Negative. Lungs: Clear. Heart: No murmur, rub or gallop. Abdomen: Nontender. Extremities: No edema. Skin: No rash.
LABORATORY DATA:
Creatinine 1.4, potassium 5.0, calcium 9.4. GFR is 51.
ASSESSMENT:
1. Acute renal failure, revolved. Renal function back to baseline.
2. Vitamin D deficiency with mild hyperparathyroidism.
3. Good blood pressure and volume control.
4. ALLERGY TO SULFA.
5. Significant lower tract obstructive symptoms with history of urinary tract infection causing sepsis.
PLAN:
1. We put him on 800 IU of vitamin D q.d.
2. We didn't change any other medications.
3. Return in 6 months.
4. Check parathyroid level, vitamin D level, iron studies, urine culture, urine protein: creatinine ratio, CBC and renal function on return.
Patient has stage III chronic kidney disease secondary to nephrosclerosis. He was admitted to the hospital in July for a urinary tract infection and acute renal failure attributed to Bactrim. At his last office visit he was having another episode of acute renal failure. His blood pressure was low at that time. Terazosin was discontinued and torsemide was decreased to 20 mg q.o.d. Since that time he feels very well but developed lower tract obstructive symptoms and placed on Flomax.
CURRENT MEDICATIONS:
1. Altace 10 mg b.i.d.
2. Amiodarone 200 mg q.d.
3. Coumadin sliding scale.
4. Coreg CR 40 mg q.d.
5. Torsemide 20 mg q.o.d.
6. Repliva q 3 days.
7. Flomax .4 mg q.o.d.
PHYSICAL EXAMINATION:
Alert and oriented x 3. No complaints of chest pain or shortness of air. Weight: 178. Blood pressure: 140/80. Pulse: 64. HEENT: Negative. Lungs: Clear. Heart: No murmur, rub or gallop. Abdomen: Nontender. Extremities: No edema. Skin: No rash.
LABORATORY DATA:
Creatinine 1.4, potassium 5.0, calcium 9.4. GFR is 51.
ASSESSMENT:
1. Acute renal failure, revolved. Renal function back to baseline.
2. Vitamin D deficiency with mild hyperparathyroidism.
3. Good blood pressure and volume control.
4. ALLERGY TO SULFA.
5. Significant lower tract obstructive symptoms with history of urinary tract infection causing sepsis.
PLAN:
1. We put him on 800 IU of vitamin D q.d.
2. We didn't change any other medications.
3. Return in 6 months.
4. Check parathyroid level, vitamin D level, iron studies, urine culture, urine protein: creatinine ratio, CBC and renal function on return.