Hello, I am new to hospital E/M coding. Can you please tell me what level you received and how you came to that answer?
Thanks in advance,
Kim, CPC
CC: LBP
HPI: CAD with s/p MI, spinal stenosis as well as ambulatory dysfunction. Patient admitted last week because of increasing back pain and shortness of breath. Workup has demonstrated small cell lung cancer. Patient complaining of back pain as well as some hip pain and some shortness of breath as well as onset of memory loss.
Medications: Currently on Lovenox, Protonix, Levaquin, nebs, Spiriva, Lexapro, Aricept, Darvocet, fentanyl, Lopressor, and aspirin.
PMH: As above.
ROS: No chest pain. She does have shortness of breath. She has no edema. She also has complains of cough. She has no nausea, diarhea, or vomiting.
EXAM: Appears to be stated age. Motor 4+/5 and sensory intact to light touch. Her reflexes are depressed globally. She has +1 pulses, no edema. Patient has exquisite tenderness in her back with rotation in both her hip and her leg as well. She is awake and alert but does seem to forget periodically while speaking to her.
I have reviewed MRI of back shows multiple areas of osseous metastasis in the area of her spine, she has in her head as well as in both femurs.
ASSESSMENT AND PLAN: Back pain. At that point, obviously this is a wide spread of metastatic disease. Unfortunately, there is not much that could be done outside pain management consult with pain control possible radiation to the metastasis areas. It may help with pain control as well as clinically indicated. We will follow her along as needed, please reconsult as needed, but at this point, possible radiation, I would not place her on brace because it would be uncomfortable at this point.
Thanks in advance,
Kim, CPC
CC: LBP
HPI: CAD with s/p MI, spinal stenosis as well as ambulatory dysfunction. Patient admitted last week because of increasing back pain and shortness of breath. Workup has demonstrated small cell lung cancer. Patient complaining of back pain as well as some hip pain and some shortness of breath as well as onset of memory loss.
Medications: Currently on Lovenox, Protonix, Levaquin, nebs, Spiriva, Lexapro, Aricept, Darvocet, fentanyl, Lopressor, and aspirin.
PMH: As above.
ROS: No chest pain. She does have shortness of breath. She has no edema. She also has complains of cough. She has no nausea, diarhea, or vomiting.
EXAM: Appears to be stated age. Motor 4+/5 and sensory intact to light touch. Her reflexes are depressed globally. She has +1 pulses, no edema. Patient has exquisite tenderness in her back with rotation in both her hip and her leg as well. She is awake and alert but does seem to forget periodically while speaking to her.
I have reviewed MRI of back shows multiple areas of osseous metastasis in the area of her spine, she has in her head as well as in both femurs.
ASSESSMENT AND PLAN: Back pain. At that point, obviously this is a wide spread of metastatic disease. Unfortunately, there is not much that could be done outside pain management consult with pain control possible radiation to the metastasis areas. It may help with pain control as well as clinically indicated. We will follow her along as needed, please reconsult as needed, but at this point, possible radiation, I would not place her on brace because it would be uncomfortable at this point.