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Hi all,
I am still getting a grasp on Critical Care I need your help, please :0)
Can someone code this hospital progress note and give me your feedback, I say this would be a 99231.
Interval history- Sleepy pt doing much better now.
Systems reviewed: Resp, GI, GU, CV, constitutional, neuro
Exam:
The status of 3 vitals, pt is malnourished
Eyes: sclera aniecteric, PERRL, EOMI
ENMT: normal ears/nose, normal hearing, normal teeth and gums, dry mouth
Neck: normal JVP, no mass
Resp: normal resp effort, normal breathing sounds,
CV: normal rhythm, no edema
GI: soft, no masses, normal bowel sounds
LN: normal cervical
M/S: normal ROM
Skin: no clubbing or cyanosis, no rash or ulcer
Neuro: normal sensation, normal muscle strength, normal reflexes
Psych: normal affect, AOX3, normal judgment and insight
A/P
1. Acute renal failure - Non-oliguric, dehydration improved rapidly, positive urine output.
2. Anemia - Improved S/P blood transfusion, no need for EPO at this point.
3. Pneumonia - Improving clinically, increase Levaquin dosage
My physician billed this a level 3 progress note. I am on the fence with this one... I say it is a level 1 progress note because the conditions are improving and on the other side of that I say it is a level 3 because diagnosis that this patient has. Any insight would be greatly appreciated!
GeminiCoder74
I am still getting a grasp on Critical Care I need your help, please :0)
Can someone code this hospital progress note and give me your feedback, I say this would be a 99231.
Interval history- Sleepy pt doing much better now.
Systems reviewed: Resp, GI, GU, CV, constitutional, neuro
Exam:
The status of 3 vitals, pt is malnourished
Eyes: sclera aniecteric, PERRL, EOMI
ENMT: normal ears/nose, normal hearing, normal teeth and gums, dry mouth
Neck: normal JVP, no mass
Resp: normal resp effort, normal breathing sounds,
CV: normal rhythm, no edema
GI: soft, no masses, normal bowel sounds
LN: normal cervical
M/S: normal ROM
Skin: no clubbing or cyanosis, no rash or ulcer
Neuro: normal sensation, normal muscle strength, normal reflexes
Psych: normal affect, AOX3, normal judgment and insight
A/P
1. Acute renal failure - Non-oliguric, dehydration improved rapidly, positive urine output.
2. Anemia - Improved S/P blood transfusion, no need for EPO at this point.
3. Pneumonia - Improving clinically, increase Levaquin dosage
My physician billed this a level 3 progress note. I am on the fence with this one... I say it is a level 1 progress note because the conditions are improving and on the other side of that I say it is a level 3 because diagnosis that this patient has. Any insight would be greatly appreciated!
GeminiCoder74
