Documentation Dissection

Transcription

1 History of Present Illness: Documentation Dissection The patient is a 50-year-old male c/o symptoms for past 4 months 1, severe 2 bloating and stomach cramps, some nausea, vomiting, diarrhea. In last 3 weeks, has had pain in middle of R side back radiates around rib cage 3, has also had stomach gurgling, with massive pain 4. Will eat and then have massive stomach cramping and diarrhea an hour later 5. Denies pain radiating to groin or into shoulder, but has had some dysuria and darker colored urine. Duration lasting 3 week(s). The course is episodic. The quality is 8 on a scale of The exacerbating factor is eating. Associated Symptoms: Constitutional Symptoms: No fever or no chills. ENT: No Sore throat. Cardiovascular Symptoms: No chest pain. Orthostatic Symptoms: No lightheadedness. Respiratory Symptoms: No shortness of breath. Oral Intake: No decreased appetite. Nausea: Yes 6. Vomiting Episodes: Few 6. Bowel Movements: Loose 6. Genitourinary Symptoms: Dysuria. Review of Systems 7 : Musculoskeletal Symptoms: Joint pain. Bilateral knees and L ankle 7. Other Significant Review of Systems: All other systems reviewed and otherwise negative 7. Past Medical/Family/Social History 8 : Medical History: Additional significant medical history: Depression, Rheumatoid arthritis, HTN. Surgical History: denies. Family History: CAD. Social History: Alcohol: Denies alcohol use, Tobacco: Denies tobacco use, Drugs: Denies drug use, Family/social situation: Works in construction in Grantsville, drinks alcohol 36 beers in a week, denies smoking, no drugs. Physical Examination 9 : General Appearance: No acute distress 9. Skin: Warm. No pallor 9. Eye: Pupils equal, round, and reactive to light. Extraocular movements intact. No Icterus 9. Ears, nose, mouth and throat: Oral mucosa moist 9. Neck: Supple 9. Heart: Regular rate and rhythm, no extra heart sounds, no murmurs 9. Respiratory: Lungs clear to auscultation bilaterally. Respirations nonlabored 9. 1

2 Abdominal: Soft. Nontender. Non distended. Normal bowel sounds. No organomegaly. negative Murphys Back: Nontender 9. Neurological: Alert and oriented times 3 9. Medical Decision Making 11 : Differential Diagnosis: Cholecystitis Nephrolithiasis Pancreatitis Hepatitis Clinical work-up/interpretation: Electrocardiogram 12 : Time 04/06/10 15:02. No ST-T changes. Normal PR & QRS intervals. Results: Results. 4/6/ :20 WBC k/ul High 13 Red Blood Cell Count 3.50 M/uL Low 13 Hemoglobin g/dl 12.0 gm/dl Low 13 Hematocrit 34.4 % Low 13 Mean Corpuscular Volume (MCV) 98.2 fl High 13 Mean Corpuscular Hemoglobin (MCH) 34.2 pg High 13 Mean Corpuscular Hgb Conc (MCHC) 34.8 gm/dl Normal 13 Red Cell Distribution Width 12.6 % Normal 13 Platelets 600 k/ul High 13 Mean Platelet Volume (MPV) 8.4 fl Normal 13 Granulocytes % 77.8 % High 13 Lymphocyte % 12.0 % Low 13 Monocyte % 6.8 % Normal 13 Basophil % 0.2 % Normal 13 Eosinophil % 3.3 % Normal 13 Granulocyte # 9.6 k/ul High 13 Lymphocyte # 1.5 k/ul Normal 13 Monocyte # 0.8 k/ul High 13 Basophil # 0.0 k/ul Normal 13 Eosinophil # 0.4 k/ul Normal 13 Sodium 139 mmol/l Normal 13 2

3 Potassium 4.9 mmol/l Normal 13 Chloride 103 mmol/l Normal 13 CO 2 27 mmol/l Normal 13 Anion Gap 9 mmol/l Normal 13 Urea Nitrogen 27 mg/dl High 13 Creatinine, Serum or Plasma 1.10 mg/dl Normal 13 Glucose Level 89 mg/dl Normal 13 Alkaline Phosphatase 153 U/L High 13 AST 29 U/L Normal 13 ALT 47 U/L Normal 13 Calcium, Serum or Plasma 9.2 mg/dl Normal 13 Total Protein 7.6 gm/dl Normal 13 Albumin 3.5 gm/dl Normal 13 Bilirubin, Total 0.3 mg/dl Normal 13 Amylase 60 U/L Normal 13 Lipase 129 U/L Normal 13 Ultrasound 14 : Abdominal, The liver is normal in size. There is no evidence of intrahepatic biliary dilatation. No hepatic masses are seen. The gallbladder is normal with no evidence of gallstones. Normal gallbladder wall thickness. There is no evidence of pericholecystic fluid. No sonographic Murphy s sign]. The proximal part of the pancreas is normal. The distal pancreas could not be adequately evaluated because of bowel gas. Normal appearance of the spleen with no evidence of splenomegaly or focal splenic masses. The kidneys are normal in size. There is no evidence of hydronephrosis. No renal masses or renal stones are seen. There is no evidence of ascites. The proximal aorta and IVC are normal in caliber. Time reported 04/06/10 13:17. Impression and Plan 15 : Diagnosis 15 : Abdominal pain R Diagnosis 15 : Irritable Bowel Syndrome 15. Discharge Plan 15 : Condition: Improved 15. Dispositioned: Time 04/06/10 15:03, To home 15. 3

4 Patient was given the following educational materials: IRRITABLE BOWEL SYNDROME 15. Counseled: Patient, Family, Regarding diagnosis, Regarding treatment plan 15. Addendum: Notes: 50 yo with hx of intermittent abd cramping with exacerbation by po intake symptoms have been more recent in last 3 weeks. Cramping resolved after admission to ED and PE here now abd soft + bs nontender w/o mass hsmegaly. Labs wnl except for alk phos. US normal patient to f/u with GI. 1 Duration. 2 Severity. 3 Location. 4 Associated sign and symptoms. 5 Context. 6 Associated symptoms supports History of Present Illness with confirmation of nausea, few vomiting episodes, and loose bowels. 7 Complete Review of Systems. 8 All Past Medical/Family/Social History components have been completed. 9 Comprehensive exam 95 guidelines. 10 Physical Examination indicates abdomen is soft, nontender, non distended, confirms normal bowel sounds, and documents no organomegaly. 11 Medical Decision Making includes multiple differential diagnoses. New problem with additional work-up. 12 Electrocardiogram is performed 1 data point. 13 Lab 1 data point. 14 Ultrasound is performed 1 data point. 15 Impression and Plan document confirmed diagnoses of Irritable Bowel Syndrome and Abdominal Pain. What CPT and ICD-10-CM codes are reported? CPT Codes: 99285, ICD-10-CM Code: K58.0 Rationales: CPT : The note documents patient admission to the Emergency Department (ED) for evaluation of severe abdominal pain. The note documents a comprehensive Past Medical, Family, and Social history and outlines significant past medical history conditions and social history habits. A comprehensive physical examination (95 Guidelines) was performed documenting at least eight organ systems. The medical decision making included multiple differential diagnoses and included orders for an electrocardiogram, lab and ultrasound to rule out certain conditions. (3 data points) The nature of the presenting problem is high, a chronic illness with severe exacerbation. This supports high complexity of medical decision making. 4

5 To locate the appropriate code selection, in the Alphabetic Index look up Evaluation and Management/Emergency Department code range directs you to Reviewing the key components in the code descriptions, CPT Emergency department visit for the evaluation and management of a patient which requires a comprehensive history, a comprehensive examination; and medical decision making of high complexity is the appropriate cod selection. Included in this service is counseling and/or coordination or care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Typically, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. It is important to note that time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time. Verify code selection in the Tabular List. An electrocardiogram was also performed in the ED to rule out any cardiovascular disease due to the rib pain. To locate the appropriate code selection in the CPT Alphabetic Index look up Electrocardiography/Evaluation it directs you to code range 0178T 0180T, 93000, 93010, and The electrocardiogram procedure was not detailed and only included interpretation and report. The appropriate code selection is CPT Verify code selection in the Tabular List. ICD-10-CM: The final diagnoses document irritable bowel syndrome and abdominal pain. In the ICD-10-CM Alphabetic Index look for Irritable/bowel (syndrome). ICD-10 provides two additional code selections for IBS including with diarrhea and psychogenic. Diarrhea is mentioned in the history and review of systems. K58.0, Irritable bowel syndrome with diarrhea is the most appropriate code to report. Abdominal pain is a symptom of irritable bowel and would not be separately reported. Verify code in the Tabular List. 5