cwestman
Networker
1) pt is s/p prostatectomy( Prostate cancer) discharged 4/21/205 re admitted 4/27 with an ileus due to urinary leak
Exam was appropriate
complexity of data reviewed met requirements
Time lines met requirements with non face to face ,face to face was 4/29 f/u from visit was well documented
medical management is where I feel criteria for TOC wasn't achieved
Assessment /plan - ileus resolved pt was much improved no further work up
Prostate Cancer/post prostatectomy - pt is under the care of Urology/oncology
noted as well pt is on 3 B/P medications clonidine is no longer required may discontinue for convenience
Provider coded 99496
Medical management I felt did not justify 99496 or 99495
Time wasn't documented I coded for level 99214 ,note was locked the same day and data reviewed was extensive
2) pt post pericardiectomy with cabg re admitted for Necrotizing fasciitis
Time lines met
Complexity of data reviewed well documented
Medical management
Provider documented that the pt would benefit from a wound vac and VN for dressing changes ,she will be following with surgeon in a 2 days
chronic conditions-
Psoriasis- pt should contact surgeon to see if its appropriate to resume meds for same
Type 2 diabetes mellitus without complications
Notes: Patient to continue on with current medications of long-acting and short acting insulin along with Farxiga and Amaryl 4 milligrams
4. Essential hypertension Notes: At goal for now continue medications as prescribed
5. Urinary tract infection without hematuria, site unspecified Notes: Currently being treated with ceftriaxone scheduled to end today
6. Acute renal injury Notes: Will monitor closely and repeat blood work in 1 to 2 weeks
7. Iron deficiency anemia due to chronic blood loss
Iron deficiency anemia due to chronic blood loss Notes: Transfuse 2 units of packed red blood cells during hospitalization. Will recheck blood work in 1 to 2 weeks and then again at the full 90 days status post transfusion
Provider coded 99496 my concern is yes this pt is high risk M&M
Chronic conditions managed that affect management of Necrotizing fasciitis, and noted to check labs post transfusion
As this visit is in a global I look to code perhaps a new problem that occurred during the hospital stay but to me this visit doesn't met criteria for TOC ,it has the feel more of a f/u ?
I would appreciate hearing what others feel about billing a TOC with the management that was documented
Exam was appropriate
complexity of data reviewed met requirements
Time lines met requirements with non face to face ,face to face was 4/29 f/u from visit was well documented
medical management is where I feel criteria for TOC wasn't achieved
Assessment /plan - ileus resolved pt was much improved no further work up
Prostate Cancer/post prostatectomy - pt is under the care of Urology/oncology
noted as well pt is on 3 B/P medications clonidine is no longer required may discontinue for convenience
Provider coded 99496
Medical management I felt did not justify 99496 or 99495
Time wasn't documented I coded for level 99214 ,note was locked the same day and data reviewed was extensive
2) pt post pericardiectomy with cabg re admitted for Necrotizing fasciitis
Time lines met
Complexity of data reviewed well documented
Medical management
Provider documented that the pt would benefit from a wound vac and VN for dressing changes ,she will be following with surgeon in a 2 days
chronic conditions-
Psoriasis- pt should contact surgeon to see if its appropriate to resume meds for same
Type 2 diabetes mellitus without complications
Notes: Patient to continue on with current medications of long-acting and short acting insulin along with Farxiga and Amaryl 4 milligrams
4. Essential hypertension Notes: At goal for now continue medications as prescribed
5. Urinary tract infection without hematuria, site unspecified Notes: Currently being treated with ceftriaxone scheduled to end today
6. Acute renal injury Notes: Will monitor closely and repeat blood work in 1 to 2 weeks
7. Iron deficiency anemia due to chronic blood loss
Iron deficiency anemia due to chronic blood loss Notes: Transfuse 2 units of packed red blood cells during hospitalization. Will recheck blood work in 1 to 2 weeks and then again at the full 90 days status post transfusion
Provider coded 99496 my concern is yes this pt is high risk M&M
Chronic conditions managed that affect management of Necrotizing fasciitis, and noted to check labs post transfusion
As this visit is in a global I look to code perhaps a new problem that occurred during the hospital stay but to me this visit doesn't met criteria for TOC ,it has the feel more of a f/u ?
I would appreciate hearing what others feel about billing a TOC with the management that was documented