Practice Economics

Paying Attention to Detail Critical in Medical Coding


 

Documentation demands attention to detail. For a patient with abdominal pain, be sure to ask: How long has the patient experienced pain? Is it generalized or in a particular quadrant? Sharp or dull? And does it radiate? And jot down the answers.

“Try to use adjectives that would give specifics regarding the complaint,” says Mary Mulholland, MHA, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania’s department of medicine. She also suggests hospitalists find out which medications a patient is taking or has taken and indicate whether symptoms have improved or deteriorated. Here’s how Mulholland would document such a case:

Initial hospital admission, level of service:

Code 99223

83-year-old male admitted from the emergency room, complaining of intermittent crampy lower abdominal pain (severe at times), blood in stool and increased weakness for three weeks, worse when getting up or standing. Patient has decreased appetite and progressive shortness of breath. His review of systems is otherwise negative.

Past medical history: Coronary artery disease and hypertension

Family history: Mother with Type 2 diabetes

Social history: Quit smoking 20 years ago

Alert: Blood pressure (90/68), pulse (88), and respiratory (24)

Eyes: Non-icteric

ENT: Dry oral mucosa

Lymphatic: Palpable nodes—right auxilla and right inguinal areas

Lungs: Clear

Cardio: Slight tachycardia, no murmurs, rubs or gallops

Abdomen: Slightly distended, tender on palpation

Skin: Slightly diaphoretic, no rashes or bruising

Neurologic: Cranial nerves intact, alert and conversant

Psychiatric: Anxious

Lab results: Blood in stool, hemoglobin (6.7), serum blood glucose (120), serum sodium (132), serum potassium (4.3), chest X-ray clear (my interpretation). Old records requested.

Assessment: Gastrointestional bleeding, tachycardia, and mild dehydration

Treatment plan: Check hemoglobin and hematocrit every six hours. Also check prothrombin time and partial prothrombin time. Repeat electrolytes in the morning. Order an X-ray of the lower gastrointestinal tract. Type and screen for 2 units of packed red blood cells, and transfuse pending repeat hemoglobin and hematocrit values. Infuse intravenous fluids at 80 cc per minute. Check electrocardiogram. Consult GI regarding endoscopy.

—Susan Kreimer

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