Wiki Level of consult

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rebec26@juno.com

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What level would you give for the following? Our auditor is saying level 1 and we strongly disagree. Thanks

reason for visit: New consult for wide complex tachycardia

cc: "i am better now. They had to change my meds in the hospital."

hpi: -----had an uncomfortable feeling in her chest and bilateral arms recently. She felt her heart pounding. She went to hospital and her heart rate was in the 130s. She was admitted for further evaluation.

Her meds were adjusted because of bradycardia. Her blood work is consistent with non st mi, which was thought due to her tachycardia and demand issues. Also, the pt was found to have abn thyroid function and thyroid nodules and will be under going further evaluation

the pt had no recurrence of cp or arm pain. She did have stress test, which was neg for ischemia. Echo showed normal ejection fraction.



There is documentation of complete pfsh, ros,& exam.
Personal order & review of ekg, order for mri, ep study, and labs. Pt signed a release for physician to obtain records from-----for her review

depending on results from ep study may need ablation or loop recorder




thank you!
 
I disagree with the auditor also but I don't even see a level 1. In order to bill for the consult you need 3/3. There's no physical exam, not even constitutional, rendering the note unbillable. If the physician used time you would be compliant. Even for companies that do not recognize consults you'd need to bill a new visit and you would still need some sort of PE.

Interested to see other opinions.
 
Tonyj said:
I disagree with the auditor also but I don't even see a level 1. In order to bill for the consult you need 3/3. There's no physical exam, not even constitutional, rendering the note unbillable. If the physician used time you would be compliant. Even for companies that do not recognize consults you'd need to bill a new visit and you would still need some sort of PE.

Interested to see other opinions.
Click to expand...



thanks for your response. I did state that there was a complete exam, ROS, and PSFH. I just didn't give the detail documentation of them. The disagreement is the HPI. Thanks
 
reason for visit: New consult for wide complex tachycardia CC

cc: "i am better now. They had to change my meds in the hospital."

hpi: -----had an uncomfortable Quality feeling in her chest Location and bilateral arms recently. She felt her heart pounding Assoc. S&S. She went to hospital and her heart rate was in the 130s Severity. She was admitted for further evaluation.

I see 4 elements of HPI. Not sure what the auditor in question is counting but I would agree with you if all other required elements are present.

Laura, CPC, CPMA, CPC-I, CANPC, CEMC
 
LLovett said:
reason for visit: New consult for wide complex tachycardia CC

cc: "i am better now. They had to change my meds in the hospital."

hpi: -----had an uncomfortable Quality feeling in her chest Location and bilateral arms recently. She felt her heart pounding Assoc. S&S. She went to hospital and her heart rate was in the 130s Severity. She was admitted for further evaluation.

I see 4 elements of HPI. Not sure what the auditor in question is counting but I would agree with you if all other required elements are present.

Laura, CPC, CPMA, CPC-I, CANPC, CEMC
Click to expand...

Thanks so much! That's exactly what we got too!
 
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