From the note as listed, there is not enough for that level of visit. There are a lot of references to other records that are not listed here, but still think there needed to be more actual documentation of the problem and the assessment.Hi I have a doc who wants to bill a 99254, inpt consult on this note. I can't get enough HPI elements though. We go by the 1995 guidelines. I'd appreciate any thoughts, suggestions, feedback.
See below note,
INPATIENT SURGERY CONSULT NOTE
Reason for Consult
is a 59 year old year old female new patient to me requested by , MD. History was obtained from transfer records. I was asked urgently to consult for poss cholecystitis
Review of patient's allergies indicates:
No Known Allergies
Outpatient Prescriptions Marked as Taking for the 1/9/12 encounter (Hospital Encounter)
Medication Sig Dispense Refill
â€¢ albuterol (PROAIR HFA) 108 (90 BASE) MCG/ACT inhaler Inhale 2 Puffs into the lungs every four hours as needed for Wheezing and Shortness of Breath. 1 Inhaler 6
â€¢ butalbital-aspirin-caffeine (FIORINAL) 50-325-40 MG per capsule Take 1 Cap by mouth every four hours as needed for Headache. 40 Cap 0
â€¢ fluticasone (FLONASE) 50 MCG/ACT nasal spray Use 2 Sprays in the nostril(s) daily. 16 g 1
â€¢ NEW DRUG Apply topically. Use COCK UP WRIST SPLINT ON RIGHT WRIST AT NIGHT
DX: cts 1 Unit 0
â€¢ SOMA 350 MG PO TABS prn
â€¢ VICODIN 5-500 MG PO TABS 1 TABLET EVERY 4 TO 6 HOURS AS NEEDED
Past Medical History
RA and anklizing spondilosis
â€¢ MRSA (methicillin resistant Staphylococcus aureus)
â€¢ RA (rheumatoid arthritis) 8/16/2010
â€¢ Asthma 8/16/2010
â€¢ GERD (gastroesophageal reflux disease) 10/26/2010
â€¢ CTS (carpal tunnel syndrome) 3/8/2011
Past Surgical History
â€¢ Appendectomy (hx question)
â€¢ Cataract extr (hx question)
due to steroid injections for AS
â€¢ Other surg hx(hx only)
ulna nerve surgery
â€¢ Colonoscopy 2004
â€¢ Marital Status: Divorced
Spouse Name: N/A
Number of Children: N/A
â€¢ Years of Education: N/A
â€¢ Not on file.
Social History Main Topics
â€¢ Smoking status: Never Smoker
â€¢ Smokeless tobacco: Not on file
â€¢ Alcohol Use: No
â€¢ Drug Use: No
â€¢ Sexually Active: Not on file
Other Topics Concern
â€¢ Not on file
Social History Narrative
â€¢ No narrative on file
Problem Relation Age of Onset
â€¢ Heart Disease Mother
â€¢ Stroke Father
â€¢ Diabetes Father
â€¢ Arthritis Other
Review of Systems
A comprehensive review of systems was negative.
Blood pressure 100/60, pulse 63, temperature 97.5 Â°F (36.4 Â°C), temperature source Oral, resp. rate 18, height 1.702 m (5' 7"), weight 70 kg (154 lb 5.2 oz), SpO2 96.00%.
She is alert. She appears in no distress.
Skin shows skin color, texture, turgor normal. No rashes or lesions..
HEENT: mucous membranes moist and PERRL.
Lungs are clear to auscultation and with good chest wall expansion.
Heart has RRR (regular rhythm and rate). The PMI is not examined. Ascultation reveals an S1 and S2.
Abdomen: abdomen normal
Extremities appear normal.
Most Recent Result (within the last 72 hours)
Result Component Current Result
Hematocrit 36.0 (1/10/2012)
HEMOGLOBIN 12.0 (1/10/2012)
PLT CNT 290 (1/10/2012)
WBC 10.1 (1/10/2012)
, Most Recent Result (within the last 72 hours)
Result Component Current Result
BUN 9 (1/10/2012)
CREATININE 0.6 (1/10/2012)
NA 142 (1/10/2012)
POTASSIUM 4.0 (1/10/2012)
*Dilated cbd, acquired
AS (ankylosing spondylitis)
GERD (gastroesophageal reflux disease)
Current medical conditions or issues: no significant and see PMI &/or Problem List.
Further testing: none.
Medications recommended: none.
Medical follow up: will follow while hospitalized doubt cholecystitis to review us
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