How would you code this 99232 or 99233? Thank you
Hospitalist Progress Note (Inpatient Stay)
History: Patient continues to have severe nausea and abd pain, RUQ. Well known history of DM.
Exam: Moderate distress. BP 123/84, HR 88, RR 21
Respiratory: Lungs clear
Cardiovascular: Mild Tachycardia
GI: RUQ Tenderness, steatorrhea
PSYCH: Awake and oriented
NEURO: No tremors
Labs: NA 135, K 4.1, C02 31, BUN 30, creatinine 0.8, glucose 104, HGB 13, HCT 30, PLT 212
Impression:
Chronic Pancreatitis
Type 2 DM
Tachycardia
Plan:
Cont. NPO Status
Cont. IV fluids
Start IV Dilaudid, 1 mg Q 4H, PRN.
Hospitalist Progress Note (Inpatient Stay)
History: Patient continues to have severe nausea and abd pain, RUQ. Well known history of DM.
Exam: Moderate distress. BP 123/84, HR 88, RR 21
Respiratory: Lungs clear
Cardiovascular: Mild Tachycardia
GI: RUQ Tenderness, steatorrhea
PSYCH: Awake and oriented
NEURO: No tremors
Labs: NA 135, K 4.1, C02 31, BUN 30, creatinine 0.8, glucose 104, HGB 13, HCT 30, PLT 212
Impression:
Chronic Pancreatitis
Type 2 DM
Tachycardia
Plan:
Cont. NPO Status
Cont. IV fluids
Start IV Dilaudid, 1 mg Q 4H, PRN.