Wiki Help With High Complexity

[jifnif]

I have a visit that is being stated as 99233 for a pt. I am only coming up with a Moderate Complexity Visit and also the dr is stating that the diagnosis is for UTI and sepsis, don't I need something to back up that the pt has been found to have both of these? Sorry for all the questions, this is so new to me and I am just trying to figure it all out. Thanks!

Impression:
-
UTI - sepsis
Polymyositis
non sp anemia
gait dysfunction
HTN urgency
Urinary retention
BPH
HTN
Hx of GI bleed
DJD
Hx of diverticulitis



Plan:
-
Good appetite - cap IV fluids
PT evaluation
anemia evaluation
change to oral antibiotic

Note:
-
83 yo M admitted form the ER - " Pt. presents with a cc of nausea/ weakness starting this past monday."
Also suffered a fall hitting his head on the sofa without LOC
Ambulates with a walker
DX was made one year ago - followed by Dr. Stone.

Alert - oriented
NAD
Good appetite
Vital Signs
Date Time Temp Pulse Resp B/P Pulse Ox O2 Delivery
7/18/09 08:00 92 Room Air
7/18/09 07:48 96.7 46 18 111/61

Lungs: clear
Heart: RSR

Pt is afebrile without leukocytosis - will change to oral antibiotic pending urine culture
Good appetite - cap IV fluids

Pre-admission Medications:
-
Spironolactone 25 Mg PO DAILY
Folic Acid 1 Mg PO DAILY
Prednisone 5 Mg PO DAILY
Methotrexate 2.5 Mg PO WEEKLY

Colace 100 Mg PO PRN
Senna 187 Mg PO PRN
Omeprazole 20 Mg PO DAILY
Timolol Maleate 0.5% Ophth Soln 1 Drop DAILY


Clinical Data:
-

Hemoglobin 10.8 gm/dL L # 7/18/09 0700
Hematocrit 31.9 % L 7/18/09 0700
White Blood Count 5.3 K/mm3 7/18/09 0700
Mean Corpuscular Volume 95 fL 7/18/09 0700
Platelet Count 170 K/mm3 7/18/09 0700

Sodium Level 133 mmol/L L 7/18/09 0700
Potassium Level 3.7 mmol/L 7/18/09 0700
Chloride Level 104 mmol/L 7/18/09 0700
Carbon Dioxide Level 23.7 mmol/L 7/18/09 0700
Blood Urea Nitrogen 15 mg/dL 7/18/09 0700
Creatinine 1.12 mg/dL 7/18/09 0700
Estimat Glomerular Filtration Rate > 60 7/18/09 0700
Fasting Glucose 99 mg/dL 7/18/09 0700
Calcium Level 8.1 mg/dL L 7/18/09 0700

 

[mitchellde]

I am not understanding the dx, the physicians states dx was made a year ago by another physician, so he has had a UTI and Sepsis for a year? This looks like a visit for a fall with a possible head injury with nausea/weakness. The other listed dx do not appear to be a part of this exam or picture. I am not seeing a 99233 at all.