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Wiki What if medicare/doesn't meet 99221?

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asasands

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One of our surgeons consulted on a patient and didn't do a review of systems. The patient is medicare. Here below is what the dr. documented:

56 year old women seen with c/c abd distention, n/v and aspiration with resp failure and INER.

CT lap amt stool and pas in colon. No free air or ascites.
Pt instubated, no hx available
exam alert intubated
HEENT perla, awake, ng tube, endo trash tube
Chest HRRR with Lungs Bilat coarse BS with Fremitis low BS rt and lt bases
Abd distended no guarding rigidity no BS
foley lt femoral central line scd's

imp:

Acute Apsiration, resp failur, copd
obstipation no obstruct color
non surg abd
recL decompression colon
GI consult will reeval if needed.

What level do you think I can give?

Thanks, any help appreciated
 
The ros is part of history and if the patient is unable to communicate then history is comprehensive. It states the patient is intubated so there you have comprehensive history. It is the exam I am not getting enough information for a 99221. I cannot get past expanded focused exam and you must be at least detailed. The general rule of thumb is if the documentation cannot support an initial level then you use the subsequent levels. I think I would query the provider to see if there is more on the exam side.
 
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