graciejean
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A neurologist sees a patient in the hospital on follow up. Detailed exam is documented. For MDM notes:
No new symptoms.
1 ?TIA/syncope
2. L facial weakness -Bell's Palsy
3. Parkinsons Disease (outpt f/u with neurologist)
MRI head to my review, no evidence of acute infarct. Continue ASA/Plavix
Awaiting formal report MRI and 2 D echo. If both neg no indication for further neurologic workup.
Will sign off for now, please recall prn.
Is this high risk because of the TIA even though there is no further symptoms? How many diagnosis would be counted? Is one stable problem counted that would only meet 99231?
No new symptoms.
1 ?TIA/syncope
2. L facial weakness -Bell's Palsy
3. Parkinsons Disease (outpt f/u with neurologist)
MRI head to my review, no evidence of acute infarct. Continue ASA/Plavix
Awaiting formal report MRI and 2 D echo. If both neg no indication for further neurologic workup.
Will sign off for now, please recall prn.
Is this high risk because of the TIA even though there is no further symptoms? How many diagnosis would be counted? Is one stable problem counted that would only meet 99231?