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Help With High Complexity

  1. #1
    Default Help With High Complexity
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    I have a visit that is being stated as 99233 for a pt. I am only coming up with a Moderate Complexity Visit and also the dr is stating that the diagnosis is for UTI and sepsis, don't I need something to back up that the pt has been found to have both of these? Sorry for all the questions, this is so new to me and I am just trying to figure it all out. Thanks!

    UTI - sepsis
    non sp anemia
    gait dysfunction
    HTN urgency
    Urinary retention
    Hx of GI bleed
    Hx of diverticulitis

    Good appetite - cap IV fluids
    PT evaluation
    anemia evaluation
    change to oral antibiotic

    83 yo M admitted form the ER - " Pt. presents with a cc of nausea/ weakness starting this past monday."
    Also suffered a fall hitting his head on the sofa without LOC
    Ambulates with a walker
    DX was made one year ago - followed by Dr. Stone.

    Alert - oriented
    Good appetite
    Vital Signs
    Date Time Temp Pulse Resp B/P Pulse Ox O2 Delivery
    7/18/09 08:00 92 Room Air
    7/18/09 07:48 96.7 46 18 111/61

    Lungs: clear
    Heart: RSR

    Pt is afebrile without leukocytosis - will change to oral antibiotic pending urine culture
    Good appetite - cap IV fluids

    Pre-admission Medications:
    Spironolactone 25 Mg PO DAILY
    Folic Acid 1 Mg PO DAILY
    Prednisone 5 Mg PO DAILY
    Methotrexate 2.5 Mg PO WEEKLY

    Colace 100 Mg PO PRN
    Senna 187 Mg PO PRN
    Omeprazole 20 Mg PO DAILY
    Timolol Maleate 0.5% Ophth Soln 1 Drop DAILY

    Clinical Data:

    Hemoglobin 10.8 gm/dL L # 7/18/09 0700
    Hematocrit 31.9 % L 7/18/09 0700
    White Blood Count 5.3 K/mm3 7/18/09 0700
    Mean Corpuscular Volume 95 fL 7/18/09 0700
    Platelet Count 170 K/mm3 7/18/09 0700

    Sodium Level 133 mmol/L L 7/18/09 0700
    Potassium Level 3.7 mmol/L 7/18/09 0700
    Chloride Level 104 mmol/L 7/18/09 0700
    Carbon Dioxide Level 23.7 mmol/L 7/18/09 0700
    Blood Urea Nitrogen 15 mg/dL 7/18/09 0700
    Creatinine 1.12 mg/dL 7/18/09 0700
    Estimat Glomerular Filtration Rate > 60 7/18/09 0700
    Fasting Glucose 99 mg/dL 7/18/09 0700
    Calcium Level 8.1 mg/dL L 7/18/09 0700

  2. #2
    Columbia, MO
    I am not understanding the dx, the physicians states dx was made a year ago by another physician, so he has had a UTI and Sepsis for a year? This looks like a visit for a fall with a possible head injury with nausea/weakness. The other listed dx do not appear to be a part of this exam or picture. I am not seeing a 99233 at all.

    Debra A. Mitchell, MSPH, CPC-H

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