Ok, this is the surgeons note?
If this is the surgeons note, you can't bill it as a consult since they are 3 of 3 and there is no exam.
Patient is a 58-year-old femal who sustained a nondisplaced intertrochanteric femurfracture Chief complaint on the left Location, after falling off her scooter Context, yesterday Duration. She is indicated for open reduction internal fixation of the left hip. We discussed the fact that she has advanded degeneratio of the hip and more than likely will need total joint arthropolasty in the future Modifying factor. Our goal at this poin is simply to get the comminuted part of the fracture healed up around the trochanters so that we have better bone purchase in anticipation of a total hip arthroplasty in the future. The patient also suffers from significant obesity Past history. She and I had a long discussion about weight loss and conditioning in preparation for most likely a total hip arthroplasty down the road. We discussed other modes of thereapy including bed rest and traction, etc.
The biggest piece of missing info in this history is the ROS, so you are stuck at Problem focused on the history, no exam, and at least moderate MDM (new problem, surgery) so this actually would support a 99231 as is.
This is just my opinion and I'm sure others will vary on what elements of HPI they assign.
Laura, CPC, CEMC
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