Gastroenterology Consultation

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What is the E/M code for this report?
HISTORY OF PRESENT ILLNESS: I was asked by Dr. _____ to see _____ in consultation for the complaints below. _____, as he prefers to be called, reports that he was fine until yesterday, ate a bowl of fruit with onset suddenly afterwards of abdominal pain. It was midabdomen, sharp in nature. He reports he took some Cirrucel and hoped that this would alleviate the symptoms. He actually went golfing and after finishing 9 holes, he reports the pain was severe, He could not continue and he then subsequently presented to the emergency department. En route, he has an episode of nausea and emesis. This consisted primarily of the food stuffs, and he also had addition emesis in the emergency department and one this a.m. He reports no change in his bowel habits recently. He did have a formed bowel movement yesterday. He reports passing a small amount of latus additionally. This a.m., he reports the pain is markedly improved. He also did have some nausea previously this a.m., but actually has a bit of an appetite at this point in time.PAST MEDICAL HISTORY: Positive for hypertension, positive for coronary artery disease.PAST SURGICAL HISTORY: Coronary artery bypass grafting.MEDICATIONS: Lopressor, Altace, Lipitor and aspirin.ALLERGIES: no known drug allergies.SOCIAL HISTORY: Negative for ethanol abuse. He denies tobacco use.FAMILY HISTORY: Noncontributory.REVIEW OF SYSTEMS: Pertinent positives are noted in history of present illness. Additionally noted some chest pressure. The rest of the 14-point review of systems was negative.PHYSICAL EXAMINATION GENERAL: Comfortable appearing, middle-ages white male.HEENT: Sclerae are anicteric.NECK: Supple.CARDIOVASCULAR: Regular.LUNGS: Clear.ABDOMEN: Soft, mildly tympantic. There is a small umbilical hernia that is readily reducible. There is also diastasis recti present. Bowel sounds are hyperactive with occasional rushes. No organomegaly is noted. No masses are palpable.GENITOURINARY: No cough impulses.EXTREMITIES: Not edematous.DIAGNOSTIC STUDY RESULTS: CT and abdominal films were reviewed. They do show evidence of a partial high-grade obstruction.ASSESSEMENT AND PLAN: Small bowel obstruction, this appears to be high-grade, otiology not completely defined. Continue with NPO status for now and IV hydration. If he has any further nausea or vomiting, I think he merits a nasogastric tubes for decompression. The pain is to obtain a follow-up CT scan in the a.m. He will follow with you. Thank you for the consultation.
 

jettagirlfl

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I would use a level 4. nut since we cannot use the family history as noncontrubutory, we have to step it down to a level 3.

The Dr must state: "noncontributory to present illness"

Hope this helps! :)
 
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