CC: Drug overdose
Duration-past few hours
A/s-attempts in past
ROS- 6 (head doesn't count, it's considered a body area)
History: Expanded Problem Focused
Exam: you state 11 systems examined. This would be comprehensive based on 95 DG's.
New prob (I'm assuming new problem) w/ work up.. 4 points
Labs 1 point
EKG 1 point
Risk: IV fluids and/or chronic illness w/ exacerbation...moderate risk
The documentation states patient was admitted. By your physician? Probably so. The documentation doesn't justify even the lowest level admission, 99221.(This requires comprehensive/detailed history, comprehensive exam, medical decision making of low/straightforward) The only difference between the higher two levels is the MDM (moderate, high, respectively..) and of course the time is different.
I, personally, would educate your physician. (Primarily in documenting a complete history..hit atleast 4 HPI elements, complete 10 point ROS..) Maybe even review a few more of his/her admissions, show them what the requirements are and what their documentation must consist of.
The note you have posted is not billable unless you take the route of billing an unlisted E/M code, 99499, sending in the documentation, and letting the payer decide how much the reimbursement is.
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