I am new to Inpatient profee coding and a provider wants to code critical care, but to me the note reads as stable, but this could just be my inexperience in this area. Would this be appropriate to code as 99291 or 99233?
DAILY PROGRESS NOTE
32yr old female admitted with the working diagnosis of Sepsis (HCC).
SUBJECTIVE
5/23: Patient arousable. She appears ill laying in bed.
Physical Exam
General Appearance: ill-appearing
Mental Status: Arousable easily but falls back to sleep.
Chest: no tachypnea, retractions or cyanosis
Heart: S1 and S2 normal, no murmurs noted
Abdomen: soft, nontender, nondistended, no masses or organomegaly
Neurological: neck supple without rigidity and arousable easily
Extremities: no pedal edema noted
ASSESSMENT & PLAN
1. Sepsis:
○ 5/23: white cell count 16.1, lactic acid initially at ten currently 3.7 and is trended up from 2.7, CRP 17.3, heart rate of 104. Patient currently on pressors. Continue IV cefepime, IV Vanco and Flagyl.
2. Hypotension:
○ Currently on pressors secondary to low MAP. Will continue to monitor closely.
3. UTI: Continue cefepime
4. AKI: Creatinine slowly trending downward. Continue IV lactated Ringer's.
5. Substance use:
○ Methamphetamine use prior to admission.
6. Hypomagnesemia: Repleted
7. Hypochloremia: On LR
8. Hypocalcemia: IV calcium gluconate
9. Hypophosphatemia: Stable continue to monitor
10. Anemia: Continue to monitor CBC.
11. Chronic Medical Hx includes:
○ Substance use hx:
○ Bipolar disorder: Continue Seroquel
○ Borderline personality disorder
○ Hypothyroidism: Continue home medication
○ PTSD:
12. Full Code
Length of anticipated stay and reason:3-4 nights
Rounding total time:60 minutes critical time with face-to-face time, discussion with hospital care team including bedside nurse, nurse supervisor, case management, rehab services, US tech.
Continued need for inpatient stay: sepsis
DAILY PROGRESS NOTE
32yr old female admitted with the working diagnosis of Sepsis (HCC).
SUBJECTIVE
5/23: Patient arousable. She appears ill laying in bed.
Physical Exam
General Appearance: ill-appearing
Mental Status: Arousable easily but falls back to sleep.
Chest: no tachypnea, retractions or cyanosis
Heart: S1 and S2 normal, no murmurs noted
Abdomen: soft, nontender, nondistended, no masses or organomegaly
Neurological: neck supple without rigidity and arousable easily
Extremities: no pedal edema noted
ASSESSMENT & PLAN
1. Sepsis:
○ 5/23: white cell count 16.1, lactic acid initially at ten currently 3.7 and is trended up from 2.7, CRP 17.3, heart rate of 104. Patient currently on pressors. Continue IV cefepime, IV Vanco and Flagyl.
2. Hypotension:
○ Currently on pressors secondary to low MAP. Will continue to monitor closely.
3. UTI: Continue cefepime
4. AKI: Creatinine slowly trending downward. Continue IV lactated Ringer's.
5. Substance use:
○ Methamphetamine use prior to admission.
6. Hypomagnesemia: Repleted
7. Hypochloremia: On LR
8. Hypocalcemia: IV calcium gluconate
9. Hypophosphatemia: Stable continue to monitor
10. Anemia: Continue to monitor CBC.
11. Chronic Medical Hx includes:
○ Substance use hx:
○ Bipolar disorder: Continue Seroquel
○ Borderline personality disorder
○ Hypothyroidism: Continue home medication
○ PTSD:
12. Full Code
Length of anticipated stay and reason:3-4 nights
Rounding total time:60 minutes critical time with face-to-face time, discussion with hospital care team including bedside nurse, nurse supervisor, case management, rehab services, US tech.
Continued need for inpatient stay: sepsis