Annie Posted Fri 11th of March, 2016 10:28:42 AM
This pulmonologist was consulted for ICU management. As you see the diagnosis are suspected and possible. What can you do for the diagnosis. I have already spoken with the doctor and he said he was consulted for ICU management and in a respiratory view nothing was wrong so there was not a diagnosis. Can you code the suspected and possible in this case?
REASON FOR CONSULTATION: ICU management.
HISTORY OF PRESENT ILLNESS: 37-year-old female patient who
initially presented with right-sided pelvic pain. She was suspected with
tubo-ovarian abscess. Today she underwent surgery and was noted to have
severe adhesions and bowel involvement so she underwent surgical therapy
for the same. Subsequent to that, she was admitted to the Intensive Care
Unit for close monitoring.
PAST MEDICAL HISTORY:
2. High cholesterol.
PAST SURGICAL HISTORY:
1. Bilateral tubal ligation.
3. Total knee replacement.
MEDICATIONS: Included in the chart and reviewed.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Never smoked. Denies alcohol or tobacco abuse.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: 10-point review of systems mainly positive for HPI.
GENERAL: She is alert and oriented x3, does not have any complaints at
this time and appears comfortable.
VITAL SIGNS: Stable.
HEENT: Pupils equal size reactive. Extraocular muscles intact.
LUNGS: Clear to auscultation.
CARDIOVASCULAR: Heart sounds normally heard.
ABDOMEN: Soft but appropriately tender from her recent surgery.
EXTREMITIES: No edema.
LABORATORY AND RADIOLOGICAL STUDIES: Available laboratory and imaging
1. Status post surgery for suspected tubo-ovarian abscess.
2. Possible bowel adhesions.
PLAN/RECOMMENDATIONS: Continue close monitoring of postoperative care per
primary team. Currently she is stable from a hemodynamic and respiratory
SuperCoder Answered Mon 14th of March, 2016 05:34:20 AM
“AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail firstname.lastname@example.org for more information.’