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Help W/ Subsequent Note

  1. #1
    Default Help W/ Subsequent Note
    Medical Coding Books
    Sorry to bother you all AGAIN w/ another note but I am having a hard time w/ our hospitalists note. I am pasting a copy so you can see what I mean. Can i even count this note as a 99231? And on top of it all, our drs pull info from the previous this allowable???? Thanks.

    PLAN: []

    cont to monitor


    Rash/bullae- likely drug reaction
    MDR Proteus UTI
    DM2 - A1c = 6.1% - good outpt control
    ARF on CKD


    Pt non-verbal. no vents per nursing.


    Item Value Date Time
    Patient Temperature 97.4 degrees F L 7/22/09 0832
    Pulse Rate 72 bpm 7/22/09 0832
    Respiratory Rate 20 bpm 7/22/09 0832
    Blood Pressure Assessment 142/70 7/22/09 0832
    Bedside Pulse Oximetry 96 % 7/22/09 0900
    White Blood Count 16.1 K/mm3 H 7/22/09 0550
    Hemoglobin 10.2 gm/dL L 7/22/09 0550
    Platelet Count 167 K/mm3 7/22/09 0550
    Sodium Level 149 mmol/L H 7/21/09 0500
    Potassium Level 4.6 mmol/L 7/21/09 0500
    Chloride Level 120 mmol/L H 7/21/09 0500
    Carbon Dioxide Level 22.3 mmol/L 7/21/09 0500
    Blood Urea Nitrogen 97 mg/dL *H 7/21/09 0500
    Creatinine 2.30 mg/dL H 7/21/09 0500
    Percent Meal Consumed 100% 7/22/09 0833
    Percent Meal Consumed 100% 7/21/09 1700
    Percent Meal Consumed 100% 7/21/09 1158
    Bedside Blood Glucose 266 mg/dl H 7/21/09 1624
    Bedside Blood Glucose 181 mg/dl H 7/21/09 2002
    Bedside Blood Glucose 190 mg/dl H 7/22/09 0631


    General: No Apparent distress
    Heart: Regular rate and rythym, no murmur, rub or gallop
    Lungs: clear to auscultation bilaterally without wheezes, rales or rhonci
    Abdomen: Soft, non-tender, nondistended, + bowel sounds
    Extremities: warm and dry without cyanosis, clubbing or edema, 2+peripheral pulses
    skin: petechial, coalescing rash on lower abdomen new today

  2. #2
    The set up of this note is confusing but I'm pretty sure there is no chief complaint. I have no idea why he is seeing this patient. If there is no chief complaint there is no visit. You could try a 99499 and send with notes.

    Just my opinion,

    Laura, CPC, CEMC

  3. #3
    Milwaukee WI
    Default Inpatient Subsequent Visit
    I agree with Laura ... I can't figure out what the chief complaint is.

    If it's separately recorded ... yes, you'd have enough for a 99231 ... you only need 2 of 3 elements for subsequent visit. You have an EPF exam and SF MDM.

    BUT where is that chief complaint?

    And, yes, especially with inpatients you can repeat history, but what is really relevant for subsequent hospital visits is the INTERVAL history ... i.e. what happened since your last visit?

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
    thanks. that helps alot. so it is okay to copy and paste history but what about the plan or what is going on w/ the pt. ie, impression and plans?

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