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How to bill for critical Care Management
My doc did a consult for critical care management. I think I need to use the 427.31 dx code but I'm not sure. Any help would greatly be appreciated. Notes are below:
ATTENDING PHYSICIAN: Stanston Spence, MD
REASON FOR CONSULTATION: Critical care management.
HISTORY OF PRESENT ILLNESS: This is a 47-year-old female with history of
gastric bypass in 2004, repair in 2012, now returned to hospital for
perforated ulcer in pouch of bypass, repaired last night by Dr. Duncan. She
has been brought to ICU following surgery for adequate resuscitation and blood pressure management.
PAST MEDICAL HISTORY: Atrial fibrillation, bipolar disorder.
PAST SURGICAL HISTORY: Tonsillectomy in 1976, gallbladder in 1996, gastric
bypass in 2004, tubal ligation in 2007, exploratory laparoscopy in 11/2011,
gastric bypass hernia repair in 2012
SOCIAL HISTORY: Negative for tobacco, drugs and alcohol.
FAMILY HISTORY: Negative.
MEDICATIONS: Metoprolol, antipsychotic medication.
PHYSICAL EXAMINATION:
VITAL SIGNS: Stable.
GENERAL: She is in _____ distress, alert and oriented x 3.
HEENT: Normocephalic, atraumatic.
CARDIOVASCULAR: Blood pressure baseline in the 100s/60s. Otherwise
hemodynamically stable.
RESPIRATORY: Extubated. Sating 98% on nasal cannula 4 liters, stable.
ABDOMEN: Dressing is clean, dry and intact. Two JP drains in place. PEG
tube intact.
ASSESSMENT AND PLAN: A 47-year-old female status post perforated ulcer in
gastric bypass pouch _____, postoperative day 0.
1. Patient off vasoactive medications. We will continue to monitor.
2. We will continue resuscitation and hemodynamic monitoring.
Thanks
My doc did a consult for critical care management. I think I need to use the 427.31 dx code but I'm not sure. Any help would greatly be appreciated. Notes are below:
ATTENDING PHYSICIAN: Stanston Spence, MD
REASON FOR CONSULTATION: Critical care management.
HISTORY OF PRESENT ILLNESS: This is a 47-year-old female with history of
gastric bypass in 2004, repair in 2012, now returned to hospital for
perforated ulcer in pouch of bypass, repaired last night by Dr. Duncan. She
has been brought to ICU following surgery for adequate resuscitation and blood pressure management.
PAST MEDICAL HISTORY: Atrial fibrillation, bipolar disorder.
PAST SURGICAL HISTORY: Tonsillectomy in 1976, gallbladder in 1996, gastric
bypass in 2004, tubal ligation in 2007, exploratory laparoscopy in 11/2011,
gastric bypass hernia repair in 2012
SOCIAL HISTORY: Negative for tobacco, drugs and alcohol.
FAMILY HISTORY: Negative.
MEDICATIONS: Metoprolol, antipsychotic medication.
PHYSICAL EXAMINATION:
VITAL SIGNS: Stable.
GENERAL: She is in _____ distress, alert and oriented x 3.
HEENT: Normocephalic, atraumatic.
CARDIOVASCULAR: Blood pressure baseline in the 100s/60s. Otherwise
hemodynamically stable.
RESPIRATORY: Extubated. Sating 98% on nasal cannula 4 liters, stable.
ABDOMEN: Dressing is clean, dry and intact. Two JP drains in place. PEG
tube intact.
ASSESSMENT AND PLAN: A 47-year-old female status post perforated ulcer in
gastric bypass pouch _____, postoperative day 0.
1. Patient off vasoactive medications. We will continue to monitor.
2. We will continue resuscitation and hemodynamic monitoring.
Thanks
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