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Resolved Need help with an Inpatient report

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KatieD_50875

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Hello,

I hope this is the right place to ask this question.

Anyway, would someone be able to assist me with an inpatient initial visit? I am moving into inpatient reports in AAPC Practicode, and basically do not know where to begin on this one. It has been a little bit since I have worked with inpatient reports. I wasn't sure if I needed to post the case here (without phi), or do something else.

Any help would be appreciated! Thank you!
 
Thanks for posting in the Free Forum.

Yes, you can share details here.

We have a "Show the Work" (AKA Provide Your Research) policy on "How Do I Code This?" Style Questions

Please include your proposed answer, guess, theory or research to the coding question. "Showing the work" helps us understand your thought process better and also helps us respond accordingly with the correct information or guidance. Naturally, do not post private patient or company information that can violate HIPAA or company policies.

Abstract the information:

This is why you had to take anatomy, physiology (A&P), and medical terminology before coming into a coding course. We suggest that you pull out your A&P textbook and your medical dictionary to keep close at hand so you can look up any word or term that you don’t understand while reading the physician’s notes. It is important to emphasize that you, as up-and-coming professional coders, need to learn to use your resources because accuracy is one of the most important things.

They must read the entire documentation – procedure notes, operative report, or history & physical -- so they can uncover the ENTIRE STORY: Who, Where, Why, What, and How!




 
Ok. Thanks. My report is an inpatient H&P. I am having trouble putting together the HPI, ROS and the exam. I'm looking in the interval history for the HPI, but it really isn't clear cut. I ended up with an expanded problem focused history(brief hpi, complete ros, pertinent pfsh). For the exam I have 2 points, cardiovascular and eyes. And for the MDM, moderate(new problem further workup, ekg, labs, and heart cath. order. MDM moderate(rx management). I have yet to level this because I am still trying to figure out what the repirt is. I am leaning toward an initial H&P, but am not sure. I've read the guidelines several times as well. Please help. Thank you again!

INPATIENT - INITIAL VISIT

Chest Pain Admission H&P *

Patient:
SEX: Female
AGE: 44 years
Private Payer (Medicare rules for 65 and older)

DATE OF SERVICE: 1/1/20XX

Associated Diagnoses: None.

Basic Information
Source of history: Family member.
Present at bedside: Family member.
Referral source:

Chief Complaint: Patient is a female with acute hypoxia during hysteroscopy, EKG changes & troponin elevation to > 6. Intubated & on decreasing FI02. PH Morbid obesity, type 2 DM s/p gastric bypass, 50 lb weight loss. FH 2 siblings with blood clotting disorder on Rx. Now on Lovenox, rectal ASA, PRN IV Metoprolol.

Review of Systems:
Constitutional: Negative, except as documented in history of present illness.
Ears/Nose/Mouth/Throat: Negative.
Respiratory: Remote smoker 15 Y ago.
Cardiovascular: Negative.
Gastrointestinal: Negative.
Genitourinary: Negative.
Hematology/Lymphatics: Negative.
Endocrine: Negative.
Immunologic: Negative.
Musculoskeletal: Negative.
Integumentary: Negative.
Neurologic: Negative.
Psychiatric: Negative.
All other systems are negative.

Health Status
Problem List:
All Problems:
Gastric bypass / 2819423013 / Confirmed
General finding of language and communication / 429020019 / Confirmed
General observation of patient 443466017 / Confirmed
Nursing observation AND/OR diagnosis 169649010 / Confirmed
Nutrition alteration / 1220901019 / Confirmed
Safety observations / 1222811017 / Confirmed
Spiritual distress / 213839019 / Confirmed
Active Problems (7)
Gastric bypass
General finding of language and communication
General observation of patient
Nursing observation AND/OR diagnosis
Nutrition alteration
Safety observations
Spiritual distress

Histories:
Past Medical History:
Active: Gastric bypass (2819423013)

Physical Examination
Eye: Sedated on Propofol.
Intake and Output
+4 L last 23 hr.
Cardiovascular: VP+2=4 cm

Health Maintenance
EKG S Tach, extensive ST depression. Today, reversal above now long QT. No Q waves. ECH sever hypokinesis most of LV with exception normal apex. Mild MR Increase RA press. Labs noted. K+ 3.3 on replacement.

Impression and Plan
Non STEMI
P; R & L heart cath.

Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX
 
Last edited by a moderator:

Do You Have Any Free Evaluation and Management (E/M) Coding Resources?​


Yes! Here are a few...

CCO has E/M thread here:


Our free EM tool is complete and available here: https://www.cco.community/threads/cco-freebies-job-aids-and-more.5491/

We also just released a CEU training Mini-Course for EM 2021 here for current CCO Club members only https://www.cco.community/resources/2021-e-m-mini-course.617/

 
Thank you for the resources Lori!
I've watched those videos several times over, and am familiar with some of the links.

I wanted to ask though if you know of any tutors or instant chat where I can post these questions. I've tried Wyzant and actually e-mailing AAPC, but there wasn't much help I could find.
 
You can pay for subscriptions like CCO Club to get answers to coding questions faster but I do not know of any place that has chats or immediate help like that.

The CCO free forum is answered just when someone has the time & is inclined to do so.
I answer many simple questions but these long Practicode things with new E/M are just not my specialty so I asked the team to look when someone has time.

 
The CCO Club is an area you find others who have similar questions as well and you can learn from each other.
 
Thank you for the link and information. I'll take a look. All these E/M cases are definitely tiring me out. I'm sure this will be a big help!
 
Are the forums in the CCO Club free? I have my CPC-A and was wondering about this because I don't really need to take a class for passing the CPC anymore.
 
No, the club is a monthly fee to be a member.

Your Pass Into The CCO Club Includes…​



  • Continued Access to All CCO Courses & Review Blitzes You’ve Purchased In The Past
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  • Access to the BHAT™ Cave
  • Ask for Help with Medical Coding, Billing, Reimbursement, Auditing, Risk Adjustment or Practice Management Challenges You’re Facing on the Job in our Private Community
  • Share Cases with Redacted Information for Community Members and CCO Staff to Answer
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