mconner001
Guest
Hi, I would appreciate an auditor's opinion on this note as to the level it supports for a subsequent hosp visit. My providers continually bill a higher level than expected. Wording in all caps are mine,
I am not seeing a 99232 here (that's what the provider submitted) . . . I also don't see a chief complaint - can I count "no clinically apparent bleeding" in the A/P section? Your thoughts and rationale would be helpful - I apparently need to either change my style of communication with the providers or adjust MY thinking. Any help would be appreciated.
Subjective:
No complaints, full breakfast, brown stool early am
Objective:
PE -
THEN HE LISTS THE VITALS
General - no acute distress
Chest - CTA- bilaterally
Heart - RRR no m/r/g
Abdomen - soft nt/nd bs+
Rectal - deferred
EXT - no pedal edema noted
LABS REVIEWED : H & H
A/P:63 yo with a hx of colon cancer s/p resection with ileostomy creation (12/2021) on CTX with recurrent bleeding with EGD x 2 with multiple treatment modalities employed - EGD 7/6 Dr. X with hemoclips, epi and cautery, repeat 7/14 with Dr. XYZ actively bleeding duodenal ulcer treated with bicap cautery and hemospray.
7/17/22: continues to do well. No clinically apparent bleeding. Tolerating diet. Possible discharged today, which seems reasonable given stability. Again, advised to ppi indefinitely - protonix or omeprazole 40mg qd. GI to sign off
I am not seeing a 99232 here (that's what the provider submitted) . . . I also don't see a chief complaint - can I count "no clinically apparent bleeding" in the A/P section? Your thoughts and rationale would be helpful - I apparently need to either change my style of communication with the providers or adjust MY thinking. Any help would be appreciated.
Subjective:
No complaints, full breakfast, brown stool early am
Objective:
PE -
THEN HE LISTS THE VITALS
General - no acute distress
Chest - CTA- bilaterally
Heart - RRR no m/r/g
Abdomen - soft nt/nd bs+
Rectal - deferred
EXT - no pedal edema noted
LABS REVIEWED : H & H
A/P:63 yo with a hx of colon cancer s/p resection with ileostomy creation (12/2021) on CTX with recurrent bleeding with EGD x 2 with multiple treatment modalities employed - EGD 7/6 Dr. X with hemoclips, epi and cautery, repeat 7/14 with Dr. XYZ actively bleeding duodenal ulcer treated with bicap cautery and hemospray.
7/17/22: continues to do well. No clinically apparent bleeding. Tolerating diet. Possible discharged today, which seems reasonable given stability. Again, advised to ppi indefinitely - protonix or omeprazole 40mg qd. GI to sign off