tracylc10
Guest
Good morning all,
I have an MD who saw a patient for a consultation in hospital observation. I am aware that Medicare does not cover hospital consultations. I am being advised by our chief MD that I should code with a New pt E/M 99201-99205. Pt has been seen in our office, but it was back in 8/2014. Here is the note. How would you code it?
Consultation Report
Labor History and Physical
LMP:11/20/2016 EDD: 08/27/2017
EGA: 10.3wks
Reason for Admission: Patient is a 32yo G3P2 at 10.3wks with 1 month history
worsening left leg pain and swelling. The patient reports transition to
sedentary work in the last few months and has prolonged episodes of
immobilization. Patient denies dyspnea, chest pain, bleeding, abdominal pain,
dysuria, hematuria and nausea.
Labs:
Chemistry Comprehensive - Last 36 hours (17) Result Date/Time
Sodium Lvl 137 01/31 23:44
Potassium Lvl 3.8 01/31 23:44
Chloride Lvl 105 01/31 23:44
CO2 24 01/31 23:44
Glucose Level 75 01/31 23:44
BUN 15 01/31 23:44
Creatinine Lvl 0.73 01/31 23:44
AGAP 12 01/31 23:44
Total Protein 6.9 01/31 23:44
Albumin Lvl 3.2 01/31 23:44
Calcium Lvl 9.3 01/31 23:44
Bili Total 0.4 01/31 23:44
Alk Phos 76 01/31 23:44
AST 20 01/31 23:44
ALT 27 01/31 23:44
GFR African Am >60 01/31 23:44
GFR Non AfrcnAm >60 01/31 23:44
Hematology Basic - Last 36 hours (24) Result Date/Time
WBC 10.93 (H) 01/31 23:44
RBC 4.13 01/31 23:44
Hgb 11.8 01/31 23:44
Hct 35.0 01/31 23:44
MCV 84.7 01/31 23:44
MCH 28.6 01/31 23:44
MCHC 33.7 01/31 23:44
RDW-CV 12.3 01/31 23:44
Platelet Count 255 01/31 23:44
MPV 9.2 01/31 23:44
NRBC Auto Rel 0.0 01/31 23:44
NRBC Auto Abs <0.01 01/31 23:44
Neutrophil Rel 70.4 01/31 23:44
Lymphocyte Rel 20.3 01/31 23:44
Monocyte Rel 6.6 01/31 23:44
Eosinophil Rel 1.9 01/31 23:44
Basophil Rel 0.5 01/31 23:44
Imm Gran Rel 0.3 01/31 23:44
Neutrophil Abs 7.70 01/31 23:44
Lymphocyte Abs 2.22 01/31 23:44
Monocyte Abs 0.72 01/31 23:44
Eosinophil Abs 0.21 01/31 23:44
Basophil Abs 0.05 01/31 23:44
Imm Gran Abs 0.03 01/31 23:44
PMH: DVT - now
PSH: n/a
OBGYN: SVD x 2 no complication no std no abnormal pap
GYN: (See Printed Prenatal Record)
All: NKA Soc: Negative x 3 Meds: Prenatals
PREGNANCY COMPLICATIONS: Above.
Vital Signs: Last Charted: 24 Hr Minimum: 24 Hr Maximum:
Temp F 98.3 (02/01 07:56) 98.3 (02/01 07:56) 98.1 (01/31 21:21)
Heart Rate 67 (02/01 07:56) 67 (02/01 07:56) 94 (01/31 21:21)
Resp Rate 16 (02/01 07:56) 16 (02/01 07:56) 20 (02/01 03:26)
SBP 118 (02/01 07:56) 106 (02/01 03:08) 151 (H) (01/31 21:21)
DBP 73 (02/01 07:56) 55 (L) (02/01 03:26) 84 (01/31 21:21)
SpO2 100 (02/01 07:56) 96 (02/01 03:08) 100 (02/01 07:56)
BMI 42 (02/01 03:52)
Hematology Basic - Last 36 hours (24) Result Date/Time
WBC 10.93 (H) 01/31 23:44
RBC 4.13 01/31 23:44
Hgb 11.8 01/31 23:44
Hct 35.0 01/31 23:44
MCV 84.7 01/31 23:44
MCH 28.6 01/31 23:44
MCHC 33.7 01/31 23:44
RDW-CV 12.3 01/31 23:44
Platelet Count 255 01/31 23:44
MPV 9.2 01/31 23:44
NRBC Auto Rel 0.0 01/31 23:44
NRBC Auto Abs <0.01 01/31 23:44
Neutrophil Rel 70.4 01/31 23:44
Lymphocyte Rel 20.3 01/31 23:44
Monocyte Rel 6.6 01/31 23:44
Eosinophil Rel 1.9 01/31 23:44
Basophil Rel 0.5 01/31 23:44
Imm Gran Rel 0.3 01/31 23:44
Neutrophil Abs 7.70 01/31 23:44
Lymphocyte Abs 2.22 01/31 23:44
Monocyte Abs 0.72 01/31 23:44
Eosinophil Abs 0.21 01/31 23:44
Basophil Abs 0.05 01/31 23:44
Imm Gran Abs 0.03 01/31 23:44
Imaging:
Radiology - Last 36 hours (1)
US LE Venous Duplex Left (01/31 23:36)
IMPRESSION:
EXTENSIVE DVT THROUGHOUT THE LEFT LOWER EXTREMITY FROM THE COMMON FEMORAL TO
THE PROXIMAL CALF VEINS.
PE:
Heart: RRR
Lungs: CTA
Abdomen: GRAVID
Contractions: n/a
Pelvis: Dilation def Effacement: _ Station: _ Presentation: _
EFW: n/a
FHT: pending
EXT: Swollen Left leg with erythema on medial aspect of the upper thigh.
Membranes: intact
Fluid: n/a
Assessment: 32yo with Left Leg DVT and pregnancy at 10.3wks.
Plan: 1. Continue Lovenox as prescribed. 2. PE precautions reviewed with
patient. 3. Follow up with me in 1 week for Continuity of care confirmation
of pregnancy and dating. After confirmation she will be referred to MFM for
consultation and coordination of high risk prenatal care.
Thank you in advance for any advice.
I have an MD who saw a patient for a consultation in hospital observation. I am aware that Medicare does not cover hospital consultations. I am being advised by our chief MD that I should code with a New pt E/M 99201-99205. Pt has been seen in our office, but it was back in 8/2014. Here is the note. How would you code it?
Consultation Report
Labor History and Physical
LMP:11/20/2016 EDD: 08/27/2017
EGA: 10.3wks
Reason for Admission: Patient is a 32yo G3P2 at 10.3wks with 1 month history
worsening left leg pain and swelling. The patient reports transition to
sedentary work in the last few months and has prolonged episodes of
immobilization. Patient denies dyspnea, chest pain, bleeding, abdominal pain,
dysuria, hematuria and nausea.
Labs:
Chemistry Comprehensive - Last 36 hours (17) Result Date/Time
Sodium Lvl 137 01/31 23:44
Potassium Lvl 3.8 01/31 23:44
Chloride Lvl 105 01/31 23:44
CO2 24 01/31 23:44
Glucose Level 75 01/31 23:44
BUN 15 01/31 23:44
Creatinine Lvl 0.73 01/31 23:44
AGAP 12 01/31 23:44
Total Protein 6.9 01/31 23:44
Albumin Lvl 3.2 01/31 23:44
Calcium Lvl 9.3 01/31 23:44
Bili Total 0.4 01/31 23:44
Alk Phos 76 01/31 23:44
AST 20 01/31 23:44
ALT 27 01/31 23:44
GFR African Am >60 01/31 23:44
GFR Non AfrcnAm >60 01/31 23:44
Hematology Basic - Last 36 hours (24) Result Date/Time
WBC 10.93 (H) 01/31 23:44
RBC 4.13 01/31 23:44
Hgb 11.8 01/31 23:44
Hct 35.0 01/31 23:44
MCV 84.7 01/31 23:44
MCH 28.6 01/31 23:44
MCHC 33.7 01/31 23:44
RDW-CV 12.3 01/31 23:44
Platelet Count 255 01/31 23:44
MPV 9.2 01/31 23:44
NRBC Auto Rel 0.0 01/31 23:44
NRBC Auto Abs <0.01 01/31 23:44
Neutrophil Rel 70.4 01/31 23:44
Lymphocyte Rel 20.3 01/31 23:44
Monocyte Rel 6.6 01/31 23:44
Eosinophil Rel 1.9 01/31 23:44
Basophil Rel 0.5 01/31 23:44
Imm Gran Rel 0.3 01/31 23:44
Neutrophil Abs 7.70 01/31 23:44
Lymphocyte Abs 2.22 01/31 23:44
Monocyte Abs 0.72 01/31 23:44
Eosinophil Abs 0.21 01/31 23:44
Basophil Abs 0.05 01/31 23:44
Imm Gran Abs 0.03 01/31 23:44
PMH: DVT - now
PSH: n/a
OBGYN: SVD x 2 no complication no std no abnormal pap
GYN: (See Printed Prenatal Record)
All: NKA Soc: Negative x 3 Meds: Prenatals
PREGNANCY COMPLICATIONS: Above.
Vital Signs: Last Charted: 24 Hr Minimum: 24 Hr Maximum:
Temp F 98.3 (02/01 07:56) 98.3 (02/01 07:56) 98.1 (01/31 21:21)
Heart Rate 67 (02/01 07:56) 67 (02/01 07:56) 94 (01/31 21:21)
Resp Rate 16 (02/01 07:56) 16 (02/01 07:56) 20 (02/01 03:26)
SBP 118 (02/01 07:56) 106 (02/01 03:08) 151 (H) (01/31 21:21)
DBP 73 (02/01 07:56) 55 (L) (02/01 03:26) 84 (01/31 21:21)
SpO2 100 (02/01 07:56) 96 (02/01 03:08) 100 (02/01 07:56)
BMI 42 (02/01 03:52)
Hematology Basic - Last 36 hours (24) Result Date/Time
WBC 10.93 (H) 01/31 23:44
RBC 4.13 01/31 23:44
Hgb 11.8 01/31 23:44
Hct 35.0 01/31 23:44
MCV 84.7 01/31 23:44
MCH 28.6 01/31 23:44
MCHC 33.7 01/31 23:44
RDW-CV 12.3 01/31 23:44
Platelet Count 255 01/31 23:44
MPV 9.2 01/31 23:44
NRBC Auto Rel 0.0 01/31 23:44
NRBC Auto Abs <0.01 01/31 23:44
Neutrophil Rel 70.4 01/31 23:44
Lymphocyte Rel 20.3 01/31 23:44
Monocyte Rel 6.6 01/31 23:44
Eosinophil Rel 1.9 01/31 23:44
Basophil Rel 0.5 01/31 23:44
Imm Gran Rel 0.3 01/31 23:44
Neutrophil Abs 7.70 01/31 23:44
Lymphocyte Abs 2.22 01/31 23:44
Monocyte Abs 0.72 01/31 23:44
Eosinophil Abs 0.21 01/31 23:44
Basophil Abs 0.05 01/31 23:44
Imm Gran Abs 0.03 01/31 23:44
Imaging:
Radiology - Last 36 hours (1)
US LE Venous Duplex Left (01/31 23:36)
IMPRESSION:
EXTENSIVE DVT THROUGHOUT THE LEFT LOWER EXTREMITY FROM THE COMMON FEMORAL TO
THE PROXIMAL CALF VEINS.
PE:
Heart: RRR
Lungs: CTA
Abdomen: GRAVID
Contractions: n/a
Pelvis: Dilation def Effacement: _ Station: _ Presentation: _
EFW: n/a
FHT: pending
EXT: Swollen Left leg with erythema on medial aspect of the upper thigh.
Membranes: intact
Fluid: n/a
Assessment: 32yo with Left Leg DVT and pregnancy at 10.3wks.
Plan: 1. Continue Lovenox as prescribed. 2. PE precautions reviewed with
patient. 3. Follow up with me in 1 week for Continuity of care confirmation
of pregnancy and dating. After confirmation she will be referred to MFM for
consultation and coordination of high risk prenatal care.
Thank you in advance for any advice.