E/M for inpatient consult paging mitchellde thomas7331


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Our billing office is under the impression that the following notes can be leveled at inpatient consult level 3. Humana thinks otherwise and wants to pay us a level 1.
Please give me your input if I should fight it. They are now beginning to request records for other inpatient consults. I am freaking out if they are going to pull all of our patients both inpatients and office. Having insomnia!

Patient was admitted at 6 pm and consult immediately seen by cardiologist at 9 pm. ICU patient. The notes are as ff:


" Patient X is a 49 year old, Caucasian man with a history of multiple sclerosis, type 2 diabetes mellitus, increased body mass index, paroxysmal atrial fibrillation. The patient is not able to tolerate beta blocker in the past because of erectile dysfunction and other complaints such as fatigue. He is maintained on Propaferone. He is currently on Propaferone 150 mg po three times daily.

The patient was trying to maintain balance by standing on an electric scooter, however the scooter fell out from under his feet and he feel and hit his buttocks and hips and back badly. He said he could hardly get up . He was hurting real bad and was straining a little bit when he felt his heart went irregular. His heart became very irregular and fast. He also developed severe chest pain with radiation of the chest pain down to his left shoulder and left arm.

He went to his house and took a tablet of Propafenone but it did not produce any relief. He came to the ER. He has atrial fibrillation with RVR at a rate of 160. He was given IV Cardizem and IV Adenosine with minimal effect. Subsequently, I was called and we switched his medicine to IV Amiodarone bolus an drip followed by intravenous Digoxin and his heart rate slowed down from 160s to 120s. But despite that, he is still having persistent rapid heart rate and a decision was made to transfer him to the ICU for intravenous drip and medical titration.

1. Multiple sclerosis
2. Paroxysmal atrial fibrillation with intolerance to beta blocker including Sotalol.
3. History of syndrome X
4. Small vessel disease
5. Stable angina pectoris
6. Increased body mass index
7. Type 2 diabetes mellitus
8. Degenerative joint disease
9. Hypertension
10. Hypercholesterolemia
11. Sinus bradycardia when given regular dose Sotalol
12 Peripheral neuropathy with diabetes mellitus
13 Hernia repair
14 Gallbladder sugery

11 meds listed

ALLERGIES Intolerant to Sotalol bec of bradycardia, erectile dysfunction and exhaustion

SOCIAL HX Former smoker, quit smoking at age of 42. Currently single. no significant alochol use no drug abue

Gen Patient alert and oriented x 3, appeared to be in no acute distress. VItal signs BP 121/100-156/104, HR 123-160. Temp 98 Resp rate 14-19/min O2 sat 97% weight 99 kg
HEENT Normocephalic anicteric sclera
NECK Supple, no JVC
Lungs Clear
Heart Normal S1S2 irregularly irregular, tachycardic
Abdomen Normoactive bowel sounds, soft, non tender
Extremeties No edema

LAB TEST Reviewed carefully INR level 1.4, creatinine 0.8, Troponin T negative, Blood glucose 192, hemoglobin 16.3

1. Paroxysmal atrial fibrillation with atrial fibrillation and rapid ventricular response which started today after a fall
2. Diabetes mellitus Type 2
3. Peripheral neuropathy
4. Multiple sclerosis
5. Hypertension
6.Intolerant to beta blocker including Sotalol bec of erectile dysfunction
7. Hyperchoelsterolemia

1. A comprehensive review of patients medications, lab test, work up results and history.
2. Prompt heart rate control. The patient had IV Cardizem drip at 0.5 mg, IV Digoxin and was started on IV Amiodarone bolus and currently on IV Amiodarone drip.
3. Additional dose of Digoxin 0.25 mg IV push x1 now.
4. Add Metoprolol 50 mg po x1 by mouth
5. Anticoagulation with Lovenox
6. Continue with Coumadin
7. Check echocardiogarm tomorrow to allow us to evaluate his cardiac size, systolic, diastolic and valvular function
8. Check 12 lead EKG
9. Close blood pressure, heart rate and rhythm monitoring
10 High level complexity medical decision making in the the hospital tonight.
11His medications will be titrated based on his clinical progress as well as hemodynamic parameters

Signed 0931 pm

How can this Level 1?? Are we missing some boxes checked? The MDM is complex.

Thank you everyone for your help. We are getting anxious and feel a Level 1 is totally unfair but we are too small to fight these insurances. Only 2 cardio in town working hard, overstretched.


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I'm imagining the issue is because of the requirements for a level 3 consult which requires 3 of 3 key components:
Detailed History: (The HPI really is only problem focused)
Detailed examination: Are you using 1995 or 1997 guidelines and which guidelines does the carrier use?
1997 guidelines for detailed exam are 12 bullet points
(1 bullet for three vital signs)
(1 bullet for general appearance)
(1 bullet for examination of neck)
(1 bullet for auscultation of lungs)
(1 bullet for auscultation of the heart)
(1 bullet for assessment of carotid arteries)
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)
(1 bullet for examination of extremities for edema)
(1 bullet for examination and/or palpation of digits and nails)
(1 bullet for inspection of skin and subcutaneous tissue)
(1 bullet for brief assessment of mental status—orientation)
Medical Decision making of low complexity: I believe this is covered


True Blue
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When you say level 3, do you mean 99253 or 99223? Just looking quickly, I see that the note above is missing a review of systems, and for a consultation or initial visit, you are not going to be able to get to a high level code without that. Also, I would count this exam as detailed at best, which could get you to 99253 if you had a ROS, but would not get you above 99221, even with complex MDM. I think that those are the weak areas in this documentation.