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level of risk??

  1. #1
    Location
    Harrisburg, PA
    Posts
    11
    Default level of risk??
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    I am auditing some of my PA's subsequent hospital notes and I am now to a point where I am stuck on this particular record. I am hoping that someone can help me out with what level of risk you would consider the following...

    1. PAD s/p fem pop bypass
    2. SVT - HR regulated no acute issues.
    3. C-Diff on vanco - positive for loose stools, ID following
    4. foot/heel ulcers - wound care following
    5. afib on coumadin rate controlled.
    6. hypothyroid, on sythroid
    7. dyslipidemia, on zocor
    8 CAD - no chest pain on ASA
    9. confusion - pt remains confused , no agittation
    10. UTI on diflucan

    Please help with what level of risk you would give this. Thanks.

    Ashley

  2. #2
    Location
    Maple Grove, MN
    Posts
    22
    Default
    I would consider this patient to be high risk. Multiple problems, some considered high risk on the table of risk.

  3. Default
    I would consider the Medical Necessity on this one to be Low. All of the problems that your PA is actually following are either Stable Chronics, or Uncomplicated Acutes. She did not even make any medication changes. Even though you could probably get Moderate on the table of risk for 2+ stable chronics, I don't see the medical necessity for going above Low based on the stable chronics and uncomplicated acutes.

  4. #4
    Default
    Quote Originally Posted by A_Warren View Post
    I am auditing some of my PA's subsequent hospital notes and I am now to a point where I am stuck on this particular record. I am hoping that someone can help me out with what level of risk you would consider the following...

    1. PAD s/p fem pop bypass
    2. SVT - HR regulated no acute issues.
    3. C-Diff on vanco - positive for loose stools, ID following
    4. foot/heel ulcers - wound care following
    5. afib on coumadin rate controlled.
    6. hypothyroid, on sythroid
    7. dyslipidemia, on zocor
    8 CAD - no chest pain on ASA
    9. confusion - pt remains confused , no agittation
    10. UTI on diflucan

    Please help with what level of risk you would give this. Thanks.

    Ashley
    Of all the conditions you have listed which ones are your docs addressing. What does the A/P look like for this encounter?
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

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