Gemini18
Expert
I have a record where the patient left the hospital AMA at 2:00pm, patient returned to the hospital and was re-admitted at 3:15pm. It was billed a 99220 - 25. Is this correct?
CC: Shortness of breath
HPI: pt is a pleasant 70-year old female who was admitted intitially on 3/1/09 by Dr. K. for acute renal failure and a. bronchitis. I saw the patient this morning and she left against medical advice, although she was significantly hypoxic, sats as low as 85% w/o oxygen. She refused oxygen and wanted to leave. The patient was brought right back to the ER and they called me to readmit her. The patient is weak all over. she denies chest pain.
No labs were drawn in the ER as they were drawn this morning.
PMH, SH, FMH
ROS: Health is deteriorating, she just left against medical advice and then did not even leave the hospital and came right back to the ER. The patient is wheezing quite a bit. The patient is short of breath. She is weak, she is hungry now. Denies chest paint. No abdominal pain. All other systems were obtained and found negative, except as mentioned above in my history of presenting illness.
PE: Vitals, skin, lymph, HEENT, chest, heart, abd, ext, neuro, psych.
Labs
CC: Shortness of breath
HPI: pt is a pleasant 70-year old female who was admitted intitially on 3/1/09 by Dr. K. for acute renal failure and a. bronchitis. I saw the patient this morning and she left against medical advice, although she was significantly hypoxic, sats as low as 85% w/o oxygen. She refused oxygen and wanted to leave. The patient was brought right back to the ER and they called me to readmit her. The patient is weak all over. she denies chest pain.
No labs were drawn in the ER as they were drawn this morning.
PMH, SH, FMH
ROS: Health is deteriorating, she just left against medical advice and then did not even leave the hospital and came right back to the ER. The patient is wheezing quite a bit. The patient is short of breath. She is weak, she is hungry now. Denies chest paint. No abdominal pain. All other systems were obtained and found negative, except as mentioned above in my history of presenting illness.
PE: Vitals, skin, lymph, HEENT, chest, heart, abd, ext, neuro, psych.
Labs