Documentation Dissection

Transcription

1 Documentation Dissection 07/07/20xx Phone call to patient post discharge: Discharged from medical center 7/5/20xx 1 dx dehydration (&HH orders) 1. I spoke with patient s niece who states she is out with patient at the store. She states he is doing much better. Still a little weak but improving daily. He is taking PO well, food and fluids and having regular BMs Patient s medications did change while in the hospital. DC orders include: stop taking Lisinopril & antibiotics Patient and niece had the following questions: What caused kidney infection. I offered that dehydration can lead to kidneys working harder and sometimes they fail. I mentioned that he needed to stay hydrated, drink as much water as possible. I also advised that she ask questions at next appointment and that provider could better answer 2. I also addressed Home Health services and the niece asked that I hold off on ordering HH until after she discusses with the patient. She will call with his decision. Adv. HH RN notified to hold off until she hears from me Patients next appointment with PCP: Dr. X on 7/14/20XX. Will call back if they can make it in sooner with openings on Friday 7/11/20XX 2. Visit: 07/14/20XX 3 Diagnosis on Discharge: PRIMARY DIAGNOSES: 1. Acute kidney injury, likely prerenal in etiology Troponin elevation, resolved Encephalopathy, resolving Hypertension Recent human T-cell leukemia-lymphoma virus infection, on Gabapentin Recent urinary tract infection. SECONDARY DIAGNOSIS: 1. Aortic stenosis 8. 1 Phone call within 2 business days after discharge. 2 Conversation documented. 3 Office visit within 14 days after discharge. 4 This is now a history of acute renal failure/injury. 5 Check body of report before reporting these diagnoses. 6 Additional diagnosis. Confirm in report. 7 This is listed as tropical spastic paraplegia below, which is reported, because the patient is being treated with gabapentin. 8 Check body of report for this diagnosis. 1

2 Family and/or caretaker present at visit: Yes, Please specify: Mary (niece) HPI: The patient is a 66-year-old male with a past medical history significant for chronic pain 9, tropical spastic paraplegia, significant peripheral vascular disease status post left BKA 10, who is admitted to the hospital with progressive weakness. Upon evaluation, he was found to have acute renal insufficiency, and this was felt to be secondary to dehydration. He was hydrated in the hospital and his renal failure resolved. Since discharge from the hospital, he s been feeling well. There was some discussion about scheduling a home health, however his niece reports that he is independent in all of his ADLs (activities of daily living) and does not feel that he needs home health assistance at this time. She does report that prior to this hospitalization, he had been complaining of back pain 11, and had been purchasing over-the-counter back pain medication (Doan s Back Pain and others). Review of Systems: Constitutional: Negative. HENT: Negative. Eyes: Negative. Respiratory: Negative. Cardiovascular: Negative. Gastrointestinal: Negative. Genitourinary: Negative. Musculoskeletal: Positive for back pain, and muscle spasms of legs and arms and weakness. Skin: Negative. Allergic/Immunologic: Negative. Neurological: Positive for polyneuropathy of feet and limbs. Hematological: Negative. Psychiatric/Behavioral: Negative. Medications on Discharge: Medication changes/adjustments: Yes, Please specify: Lisinoopril held (see below) 1. Acetaminophen/hydrocodone 325/10 one tablet 3 times a day p.r.n. pain. 2. Aspirin 81 mg daily. 3. Cilostazol 50 mg b.i.d. 4. Ferrous sulfate 325 daily. 5. Gabapentin 600 mg tablets 1-1/2 tablets t.i.d. 6. Multivitamin daily. 7. Tylenol 325 mg tablets 2 tabs q4 hours p.r.n. pain. 8. Baclofen 10 mg t.i.d. 9. Metoprolol succinate 25 mg extended release daily Important diagnosis. 10 Another diagnosis. Check body of report to see if this is addressed. 11 Back pain diagnosis. 12 Complete medication list with discontinued medications. 2

3 DISCONTINUED MEDICATIONS: Lisinopril 10 mg daily has been temporarily discontinued until the patient can see his primary care physician and have a recheck of blood pressure and potentially renal function. Past Medical History: 01/20XX: Tropical spastic paraplegia, HTN (hypertension), Erectile dysfunction, Systolic murmur 09/20XX: Aortic valve stenosis, moderate, Polyneuropathy, Hand deformities, Vascular disease, peripheral, Diastolic heart failure Past Surgical History: Procedure: neck (disc), right leg Diagnostic tests reviewed/disposition: Summary from discharge note-- LABORATORY DATA: White blood cell count on discharge is 4.6, hemoglobin 10.2, creatinine on admission 6.3 from a baseline of 0.9, at discharge 2 days later it is again 0.9, BUN on admission was 77, at discharge it is 37, potassium is 3.7, magnesium 1.7. Troponin initially 0.13, declined to 0.06 on recheck. Urinalysis showed negative nitrites, trace white blood cells, but only 2 white blood cells noted, few bacteria, not cultured. Blood cultures have been negative for the duration of this day. PERTINENT IMAGING: Exam: 1. CT scan of the brain showed no evidence of mass, hemorrhage, or acute stroke. There was evidence of atrophy and small vessel ischemia. 2. Chest X-ray showed no evidence of acute cardiac or pulmonary disease on a formal read. 3. EKG on admission showed sinus rhythm with a rate of 63, left ventricular hypertrophy with repolarization abnormality. 4. Repeat EKG showed sinus bradycardia with a rate of 54. It also showed left ventricular hypertrophy with repolarization abnormality, T waves normal than on admission but flattening in leads 3 and AVF as well as AVL and V6. Family, social, past medical and surgical histories reviewed and updated. BP 150/66 Pulse 63 Sp02 96% Constitutional: He is oriented to person, place, and time. He appears well-developed and well nourished. No distress. HENT: Head: Normocephalic and atraumatic. Right Ear: External ear normal. Left Ear: External ear normal. Nose: Nose normal. Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate. Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light. No scleral icterus. Neck: Normal range of motion. Neck supple. No thyromegaly present. Cardiovascular: Normal rate, regular rhythm and intact distal pulses. No extra systoles are present. Murmur heard. Systolic murmur is present with a grade of 3/6. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes. Abdominal: Soft. Bowel sounds are normal. He exhibits no distension and no mass. There Is no tenderness. There is no rebound. Musculoskeletal: He exhibits no edema and no tenderness. Status post left BKA. Lymphadenopathy: He has no cervical adenopathy. Neurological: He is alert and oriented to person, place, and time. Skin: Skin is warm and dry. Psychiatric: He has a normal mood and affect. His behavior is normal. 3

4 ASSESSMENT: 1. Acute renal failure secondary to NSAID usage History of elevated troponin, rule out for acute coronary syndrome 3. Aortic valve stenosis 4. Hypertension 5. Chronic pain/peripheral neuropathy due to tropical spastic paraparesis and peripheral vascular disease PLAN: 1. Discussed interaction of NSAIDs with his current medications. This is the most likely reason why he developed renal failure, as he started to use the over-the-counter NSAIDs about 2 weeks prior to his admission to the hospital. Avoid the over-thecounter pain medications unless cleared by the clinic. 2. Will check BMP today, if renal function has improved, will plan to restart lisinopril. 3. Significance of elevated troponin unclear, in the setting of acute renal failure. He did have some EKG changes, but was completely asymptomatic from a cardiovascular standpoint. He does have known coronary vascular disease 14. Will continue to monitor. 4. Increase Gabapentin to 1200 mg by mouth three times daily to treat nerve pain from tropical spastic paraplegia (Human T-cell leukemia-lymphoma virus I infection) and peripheral vascular disease. 5. Follow-up in clinic in 2 3 weeks 15. Disease/Illness education for self-management, independent living and ADL s 16 (please populate patient education in patient instructions): Discussed (as above). Home health/community services discussion/referrals 17 : Declines referral to home health currently. Discussion with other health care providers: No. Assessment and support of treatment regimen adherence: Reviewed NSAID usage (as above) with patient and niece. Advanced Directives paperwork given/sent to patient on 7/21/20XX. Durable Power of Attorney (person who would make medical decisions for patient if patient unable to do so): Niece 18. POLST form: When you are at the end of your life, what do you want to have done/not done? Discussed with patient, will further clarify at future office visit. 13 This is now a history of acute renal failure. 14 Known CAD additional diagnosis. 15 Important for Transitional Care Management coding. 16 Education to support self-management. 17 Identification of community and health resources. 18 Supports Transitional Care Management Services. 4

5 Palliative Care Discussion: Will schedule separate appointment to discuss further. 45 minutes was spent with this patient and over 50% of the time was spent on educating renal failure, NSAID usage 19. 7/15/20XX 20 to patient s niece 21 (Proxy for patient): Restart Lisinopril I hope you received the message regarding the labs from yesterday. His kidney function looks good, so it s all right to restart his Lisinopril at the regular dosage. Let s plan to see him back in 2 3 weeks to make sure that everything is going well. Do you want to schedule an appointment online, or if it s easier then you can call the office to schedule. Looking forward to seeing you in a few weeks! 19 Discussions with patient. Prolonged services cannot be reported. 20 Additional contact with patient s family during the post discharge time frame. 21 Important communication with patient/family following face-to-face visit. What are the CPT and ICD-10-CM codes reported? CPT Code: ICD-10-CM Codes: I10, G04.1, I73.9, G89.29, I25.10, I35.0, Z87.448, Z Rationales: CPT : The Medical decision making is defined by E/M services guidelines and the date of the first face-to-face visited. The faceto-face visit was within 14 days of discharge. Communication (direct and via was met), interaction with Home Health Care, education, and directives discussed, and follow-up in 2 to 3 weeks. The number of diagnosis or treatment options: 4. Monitoring acute renal failure due to NSAID usage stable. Hypertension Chronic pain due to tropical spastic paraplegia (human T-cell leukemia-lymphoma virus infection) and peripheral neuropathy which is a symptom of tropical spastic paraplegia and peripheral vascular disease. Will monitor elevate troponin. Amount and complexity of data: 3 Will check renal function (1). Reviewed and summary of labs, X-rays, EKG from discharge (2). Highest risk option: 3 Review and change of medications Lisinopril and Gabapentin. MDM = Moderate based on 2 of the 3 elements. Report for transitional care management services. 5

6 ICD-10-CM: This patient is not actively being treated for acute renal failure, because his values are now normal. His renal function will be monitored. He has a history of renal failure. He is being monitored for hypertension and chronic pain due to polyneuropathy for peripheral vascular disease and muscle spasms from tropical spastic paraplegia. Look in the ICD-10-CM Index for Hypertension leading to I10. There is no mention that the hypertension is related to the aortic stenosis and would not be coded as hypertensive heart disease. Next, look in the Alphabetic Index for Stenosis/aortic (valve) leading to I35.0. In the Alphabetic Index look for Paraparesis which states to see paraplegia. Look up Paraplegia/spastic/tropical that leads to G04.1. Polyneuropathy is a symptom of tropical spastic paraplegia and would not be separately reported. Chronic pain is also documented and would be important for the assessment of health needs. Look in the Alphabetic Index for Pain/chronic G Do report the peripheral vascular disease. Look in the Alphabetic Index for Disease/peripheral/vascular NOS leading to I73.9. You can also code the known coronary artery disease which supports the medical necessity for checking troponin levels. Look in Alphabetic Index for Arteriosclerosis/coronary artery leading to I Next in the Alphabetic Index look up History/personal/disease or disorder/ urinary system NEC Z The patient also has a (below knee amputation) BKA, which is important to know for the assessment of health care needs. Look in the Alphabetic Index for Absence/extremity/lower (above knee) Z The Tabular list shows a 6th character is required for laterality. Report Z for BKA left. Verify the codes in the Tabular List. 6