Elizabeth83
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I would like to know others opinions on this. Any auditors out there? Thank you
99202 verses 99203.
The patient has a stable chronic illness, 1 data, and gallbladder disease symptoms discussed, with patient to follow up PRN.
HISTORY OF PRESENT ILLNESS
The patient is here for evaluation of gallstones. gentleman who states that he had a workup with an ultrasound of the abdomen because he had black stool several months ago. He has not had that episode anymore. He denies any abdominal pain. He pretty much eats whatever he wants. He does suffer from esophageal reflux and he takes famotidine with usual control of his reflux. In any case, when he had the ultrasound of the abdomen, it showed cholelithiasis, and, given these findings, he comes in for general surgical evaluation. At this point, he is not really describing any symptoms of biliary colic.
PROBLEM 1
COMPLAINT
Complaint: Evaluation for gallstones.
ABDOMEN:
Visual Inspection: The abdomen was not distended.
Auscultation: The bowel sounds were normal.
Palpation: The abdomen was soft, no abdominal guarding, abdominal non-tender + rectus diastasis, and no abdominal rebound tenderness. No mass was palpated in the abdomen.
TEST CONCLUSIONS
I reviewed the ultrasound of the abdomen and this shows cholelithiasis without evidence of cholecystitis and hepatomegaly.
ASSESSMENT
81 year old gentleman with asymptomatic gallstones.
PLAN
I did discuss with him at length the signs and symptoms of gallbladder disease and he voiced understanding. Followup prn.
99202 verses 99203.
The patient has a stable chronic illness, 1 data, and gallbladder disease symptoms discussed, with patient to follow up PRN.
HISTORY OF PRESENT ILLNESS
The patient is here for evaluation of gallstones. gentleman who states that he had a workup with an ultrasound of the abdomen because he had black stool several months ago. He has not had that episode anymore. He denies any abdominal pain. He pretty much eats whatever he wants. He does suffer from esophageal reflux and he takes famotidine with usual control of his reflux. In any case, when he had the ultrasound of the abdomen, it showed cholelithiasis, and, given these findings, he comes in for general surgical evaluation. At this point, he is not really describing any symptoms of biliary colic.
PROBLEM 1
COMPLAINT
Complaint: Evaluation for gallstones.
ABDOMEN:
Visual Inspection: The abdomen was not distended.
Auscultation: The bowel sounds were normal.
Palpation: The abdomen was soft, no abdominal guarding, abdominal non-tender + rectus diastasis, and no abdominal rebound tenderness. No mass was palpated in the abdomen.
TEST CONCLUSIONS
I reviewed the ultrasound of the abdomen and this shows cholelithiasis without evidence of cholecystitis and hepatomegaly.
ASSESSMENT
81 year old gentleman with asymptomatic gallstones.
PLAN
I did discuss with him at length the signs and symptoms of gallbladder disease and he voiced understanding. Followup prn.