Hpi Elements

8/10/2019 Hpi Elements

1/55

Rajitha Mannem ; Shravya Vaddiraju; Laxmi Kanth Singh G ; SriLakshmi Sravanthi Tirumala Raju ; Arun Kumar Basa Govind; Vamshi Mary Thumma; Pavitra Swapna Namburi; Vishnu Venamma Puchalapalli; Theja Katipally ;

Sravani Mallampati ; Neha Reddy Ponagandla; Ramesh Edunoori ;Koushik Adlluri ; Swetha Varanasi ;Chaitanya Pamidi ; Pavan Kumar Medicherla; Siri Mamatha Chennuru; Gazal Pandey ; AnnapuranaYellakarri ; Vani Sharma ;Pratyaksha Boora ; Sandeep Sikar; Swathi Katta ; SumanReddy Gottam; Manjeerabai U ; Analtej

Ambati ;

We will assemble by 5:00 PM as some of our team members are in a meeting.

Hi All,

Today we are celebrating Shravya birthday. Cake cutting will be at 4:00 pm, so please give 50 Rs to Arun.

Team:

Please assemble in 11 th floor by 4:45 PM.

Bakery:-9959961946


2/55

Radiation oncology format dont code ( Nicole ross ) crnp)

[email protected]

[email protected]

RHEMAT take max

http://pshrprd.suth.com/psp/H91PRD/EMPLOYEE/HRMS/h/?tab=DEFAULT

Good Morning ..

AdlluriK password1

AdlluriK password1

Auto mouse mover

Hunter@5
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


3/55

.. Dr. Jo Buyske is part of Trauma not GI Surgery

Garfall or grafall (onc)

Consider ROS :-

583971- Maheswari

583688- akh

Manju.ezhumalai@ omegahms.com

AI modifier used when initial visit down coded as sv and initial CC

\\inhjsfs02\medicalcoding$\Training Batches\Experienced coders_April 2014

\\hydlanfnp01\medicalcoding$\Training Batches\Experienced coders_April 2014

http://www.medilexicon.com/medicaldictionary.php?t=83046
http://inhjsfs02/medicalcoding$/Training%20Batches/Experienced%20coders_April%202014http://hydlanfnp01/medicalcoding$/Training%20Batches/Experienced%20coders_April%202014http://www.medilexicon.com/medicaldictionary.php?t=83046http://www.medilexicon.com/medicaldictionary.php?t=83046http://hydlanfnp01/medicalcoding$/Training%20Batches/Experienced%20coders_April%202014http://inhjsfs02/medicalcoding$/Training%20Batches/Experienced%20coders_April%202014


4/55

VENKAT -9866045717=FOR ACCOUNT LOCK

GSD :- 582986, 6400, 9885457586, VENKAT -9866045717

SOME can be taken as history element

Pratyaksha Boora ; Keerthi Madeti ;Maheswari Hanumantha Kari ; SushmaReddy Masku; Vani Sharma ; Analtej Ambati; Annapurana Yellakarri ; Gazal Pandey; Sushma Bangari ; Sandeep Sikar; MridulaPavani G ; Pavitra Swapna [email protected] ; [email protected]

Sri Lakshmi Sravanthi Tirumala Raju ;

Location, quality, severity, duration, context, modifying factors and the associated signs and symptoms reported by the patient. A

majority of practitioners and office staff know the e lements of History of Present Illness (HPI), but few actually have a good

understanding of what each of the elements represent within a medical record. The following is a brief description of each element and

some examples to guide the practitioner or staff member in correctly scoring the HPI.

Location Where on the body is the sign or symptom located? This can be something as simple as leg, arm, back or head, but can

also be described by using words such as bilateral, unilateral, anterior and posterior.

Quality This is a description of the sign or symptom. Words such as sharp, dull, stabbing, loose, hard, throbbing, etc. are often used

to describe the quality of a sign, or symptom. A physician who describes a patients condition as being acute, chronic, improving or

stable may also receive credit for quality as a HPI element. For chronic conditions, descriptions such as controlled and uncontrolled

may be counted as a quality.

Severity This describes the intensity of a sign, symptom or condition. This ca n describe the patients condition on a scale of 1 -10, or

compare the pain quantitatively or qualitatively to previously experienced pain (better or worse). Additionally, severity can be

described by the conditions effect on activities of daily living. For example, patient is unable to perform ADLs due to pain.

Duration This describes how long a patient has had a sign, symptom or condition. Examples are: three weeks, since childhood,

diagnosed last year, or since last visit.

Timing Describes when a sign, symptom, or condition happens. Examples are: daily, during the day, only at night, continuous, or

intermittent.
mailto:[email protected]:[email protected]:[email protected]


5/55

Context This describes what proceeds or accompanies a sign, symptom, or condition. Examples are: while standing up, during

sleep, after eating, during exercise. It can also describe the emotional state of a patient while a symptom occurs: when stressed, when

anxious, or when aggravated. For chronic conditions, other factors such as family history of a certain disease or existence of other

symptoms or disease process can be counted for context. For example the patient is experiencing dizziness due to hypotension.

Modifying Factors This tells us how the patient can manipulate their body to reduce or increase the current condition. The

documentation would reflect what the patient does for relief, what makes the symptom worse, or what medications have been taken.

Examples would be: better after taking antacid, worst while laying on side, or better when sitting up.

Associated Signs and Symptoms These are signs or symptoms that accompany a condition. Examples can be: fever and chills that

accompany a chief complaint of stomach pain; sore throat and sinus pain that accompany a cough; numbness and tingling

accompanying pain in the leg. Symptoms that do not occur normally during a disease process but may be present, nonetheless, may

also be counted as an associated sign or symptom, as can the lack of associated signs and symptoms.

Element How do you describe the symptoms? Sample words

Location Where is the patients pain? Where do the symptoms occur?

Chest, lung, head, stomach

Quality What is it like?What are the characteristics of the symptoms?

Burning, dull, sharp, green, bright,stabbing, scratchy, red

Severity How bad are the symptoms? Better, worse, increasing, decreasing,well, same, 5 of 10 on pain scale, BPhome shows good control

Duration When did the symptoms start?How long has the patient had the symptoms?

Today, weeks, months, longstandingyears

Timing When do the symptoms occur? Upon awakening, intermittently,always, still, continuous, after meals,

daily, during the day, only at night,continuous, or intermittent.

Context Are the symptoms associated with anyactivities?

After surgery, in a motor vehicleaccident, when elevated, at work

Modifying factors What has the patient tried to relieve thesymptoms?

With ice, using meds, with OTC lotion

Associated signs andsymptoms

What other symptoms does the patient have,associated with the presenting problem?

Fever, confused, achy, weakness, pain,fatigue, swelling

Quality: What is the nature of the patient's symptoms? What is it like? What characteristics describe the symptom?Typically this will include colors, such as green, red, or yellowish. It will include a description of the type of pain: burning,stabbing, dull, achy, etc.

acute, chronic, improving or stable

Characteristics ofthe symptom(s) How it looks orfeels

Severity: That is, how bad are the patient's symptoms? Are they getting better or worse, increasing or decreasing?Sometimes a clinician might note the pain scale that the patient is having, such as 9 of 10. The patient might be feelingwell or okay.


6/55

How bad is it?

Duration: How long has the patient has these symptoms? It could be short. That is, the patient had them in the middle oflast night, the symptoms have lasted for 24 hours, or it could be a longer time, such as longstanding, months, years. Anydescription about the duration of the length of the patient's symptoms, illness or condition can be used as an element ofduration.

Timing: That is, under what circumstances do the symptom occur? Is it intermittent, continuous, constant, uponawakening, still, or after exercising? Those are the kinds of words, which can be used to describe the timing of a

symptom.

daily, during the day, only at night, continuous, or intermittent.

Context: In order to answer this question, consider in what context the patient's symptoms occur. Did they happen after amotor vehicle accident, after slipping on the ice, or in relation to another illness or surgery?

EX:- while standing, during exercise, after a fall

What the patient was doing or circumstance surrounding the complaint

Where & what were you doing when it started?

Modifying factors: The modifying factors are any treatments prescribed by a physician or tried by the patient withoutphysician direction, which the patient has used to try and improve their symptoms. It could be that the patient has been onantibiotics already for a week, or that the patient has tried elevating their leg without relief, or that they have tried over-the-counter medications. Aspirin, rest, antibiotics, CABG.

Associated signs and symptoms . That is, other findings that the patient presents with, related or unrelated to today'schief complaint. It could be that the patient came in and also complained of fever, weakness, confusion--any other

symptom, which the patient describes. We typically think of these elements as positive complaints, but many auditors willuse a negative response in associated signs and symptoms.

Past, Family & Social HistoryPast medical, surgical history, hospitalizations, operations, immunizations, medications, dietary feeding status, allergiesFamily family health status/cause of death, diseases related to CC, hereditary diseases or those that place pt. at riskSocial marital status, ETOH use, smoking, occupation, education level, sexual history, other relevant factors

PFSH Level - Brief 1 element from 1 category Complete 2-3 elements from 2-3 categories depending on code

Hereditary coproporphyria ( HCP )

komariP

komari*100

ed to ip ---tran, op , op surg, obser

req, render, respo=consul


7/55

axk1012 and Hunter@1 for encoderpro also

MYERS JENNIFER S MD (HSP)

Admit:-CAITLIN MARTIN KLINGER MD (HSP)Att:- AIRAN JAVIA, SUBHA MD (HSP)

CHARU AGGARWAL MD ARTURO LOAIZA-BONILLA MD

FALK, GARY W MD

Ad:-KRISTY REINERT MD (HSP) Att:- HECHT TODD MD (HSP)

DAS RITUPARNA MDAtt:- MYERS JENNIFER S MD (HSP)

SCHUTTA MARK HPRASAD, MEETA MDLAUREN FISHBEIN M MD

UMSCHEID, CRAIG A., MDPRICE, RAYMOND MDPATEL, NEHA MDSAVITZ JODI MD================13,5PATEL, NEHA MD

Admit:-MIGNOTT HAROLD MD (HSP) ATT:-MYERS JENNIFER S MDMAKAR, GEORGE (GAS)VANDANA KHUNGAR MD (GAS)JUNKO TAKESHITA MD (DER)

ALBELDA STEVEN M MD (PUL)DINE CONSTANCE J

MYERS JENNIFER S MDSMITH,KERRI A MDJINGMEI HSU MD (ONC)

Shah and Shaffer (onc) non billable

SAVITZ JODI MD

MYERS JENNIFER S MDHECHT TODD MD (HSP)99223 AND 99239CONSULT ASK ARUNPRUITT AMY MD

ARTURO LOAIZA-BONILLA MD(ONC)99232VANDANA KHUNGAR MD (GAS)GROSSMAN ROBERT A MD

HECHT TODD MD (HSP)

BEN STANGER, MD.

HECHT TODD MD (HSP)

SHASHATY,MICHAEL MD (PUL


8/55

SHASHATY,MICHAEL MD

Could you please provide the details of below shown new providers..

1. Renal : Patcom#-215075963 (Pg # 4 of Renal consultation) Kaur, Navdeep-NPI# 1366685612 EPIC Provider#R09948

a. Onc : Patcom#-215437239 (Pg # 11 of Pn 1-5 days) Mato, Anthony NPI# 1053473983 Provider#052225

2. Onc : Patcom#-215670672 (Pg # 4 of PN 1-5 days) Waxman, Adam NPI# 1669766275 Provider #R08064

3. Psych : Patcom#-215488265 (Pg 4 of consults) Baldassano, Claudia NPI# 1598772048 Provider # 314575

Neuro : Patcom-214828974 (page 2 of PN 6 to 10 days)


9/55

Maus,Douglas MDNPI#1447315650 EPIC # 17146578

GYN: Added one more provider. Patcom-216076143 (Page 3 of progress notes). Two charts are pending for thisprovider services.

Dokras, Anuja MD- NPI# 1740274935 EPIC provider # R01674

Could you please identify the below shown two providers and forward the details to us.

Renal : Patcom-216312233 (Page 17 of progress notes 1-5 days)

1 Chart is pending for this provider service.

GYN: Patcom-215792161 (Page 4 of progress). Traxler, Sarah MD NPI# 1538301650 - EPIC provider #R11156

2 Charts are pending for this provider services.


10/55

KOBRINSIDNEY M MD

CCOPS=07/04=CC 120 min 29 7 and 8 page 07/05=80min

1) 214873426DLBCLJINGMEI HSU MD (ONC). DANIEL J LANDSBURG MD

2) 215183122

Asthma exhab

KAI XU

3) 215204753Hypokalemic paralysisMILLER, JEAN C. MD (GIM)EMMANUEL S. KING, MD

5) 215114531

JINGMEI HSU MD (ONC). DANIEL J LANDSBURG MD

Mm, hypercal, afib, htn (7 and 8 th page palliative care )

07/07=D/C 99238


11/55

JAMIE E SENGER CRNP

4)215200462

UMSCHEID, CRAIG A., MDIDDM

5,6 sv dia 07/04-may be time based coding 99232 are 99233 ----- 9,10-07/06 sv dia-----13,14 and 15=07/07 sv dia,

LAUREN FISHBEIN M MD

1)215205172

MILLER, JEAN C. MD (GIM) (ADM)

CHF

EMMANUEL S. KING, MD (ATT)

1)215200595

AD:- GREENBLATT, JEFF (HSP) Att:- SARA A VAN CALCAR MD (HSP)

CAITLIN MARTIN KLINGER MD

3) 215186844

ARTURO LOAIZA-BONILLA MD (ONC) Abd PAin

2) 215130347

JINGMEI HSU MD (ONC)

DANIEL J LANDSBURG MD

3) 215251093


12/55

Synope

CAPRICE L CADACIO MD (HSP)KIRSTIN S KNOX MD (HSP)4,7,425.4, 787.3, 780.2, 786.05

4)215238256.

MYERS JENNIFER S MD (HSP)

5) 215206170

ARTURO LOAIZA-BONILLA MD (ONC)789.0, 786.09, 174.9 285.9,9.12

Gi bleed , chf

AIRAN JAVIA, SUBHA MD (HSP)CORRIE STANKIEWICZ A MD (HSP)PATEL, NEHA MD (HSP)789.0, 427.31, 428.32, 427.23

528.9, 584.9, 496,

Completed not need of coding consultation

6)215298219.RANJEETA R BAHIRWANI MD (GAS)

Rectal bleed07/09- sigmoidoscopy done by Gary Lichtenstein07/09/2014=99223,07/10/=99238

)215247810BRENDAN WEISS MDCut t cell lymphoma780.60,202.80, 356.9,705.83

215186844 ARTURO LOAIZA-BONILLA MD (ONC)789.0, 453.40, 284.09,209.60

No D?C ???/

215264682HECHT TODD MD (HSP)

215264682

GORAL SIMIN MD10=231 and 11=D/cGLUCKMAN STEPHEN MD7 and 8 07/10 renal12 and 13 07/11 Renal


13/55

11 page dut

HIV,

)215214596(TB)EMMANUEL S. KING, MD (GIM)

12,13 ID 07/10, 17,18=ID 07/11 ,,07/07=IC,14,15 ==pul, 19,20 07/11 wr iting s, IC 07/07

415.19, 706.1, 300.00, 793.19

Check PULconsultationsCheck surgires (PX)=07/11-broncoscopy by DANIEL STERMAN

12 and 13 th page IFD 99231 07/1014 th pul 07/10,,,,,19 and 20 07/11

1 and 2

215206386 ADM:- HAAS, NAOMI S MD (ONC) ATT:-RIMINI A VARGHESE MD (ONC)SIRS07/07=99223

215420599SIRS

ARTURO LOAIZA-BONILLA MD (ONC)

511.9, 162.9, 244.9, 530.81

1)215325814

ADM:-COLLMAN RONALD MD (PUL) ATT:-SAVITZ JODI MD (HSP)

Diabetic keto acidosis07/10==99223( 7 and 8 ) pg :-11 ,,DIA =07/10 =(99232 GC),,15, 16,17 also 99232 ..07/11 GC 18 and 19 =07/12 99232 7/09=99255

07/11=99233= savitz

250.10, 616.10, 682.6, 401.9,18

215485816

ARTURO LOAIZA-BONILLA MD (ONC)hypercalcemia

275.42, 174.9,564.00, 783.41

215265481

Hecht, Todd E (HSP)Seizers


14/55

17, 18 07/10 normalHAAS, NAOMI S MD (ONC)SCHUSTER JAMES M MD (NSU)

15 and 16 =07/10,PUL, 23 and 24 07/12 PUL 07/09= intial14 onc consult 07/09 , 22 th page (dont code becoz endoscopy is planned before )19 NS 07/10

22 07/11 PUL bronchoscopy (DANIEL STERMAN) no need to code.

Lung mass , seizers,786.6, 345.9DINE CONSTANCE J07/09/2014= PUL

) 215389331

DINE CONSTANCE J (PUL)LAUREN FISHBEIN M MD

786.09, 494.0, 553.3, 327.23

215378482SARA A VAN CALCAR MD (HSP)Meningitis07/10=9922307/11=99232, 07/12=-99239322.9, 288.50, 787.01KEITH HAMILTON W MD

214373047AMLLUGER SELINA MD (ONC)Non billable CRNP

07/07=99223DANIEL J LANDSBURG MD (HEM)205.00, 300.00(206.00-monocytic)JINGMEI HSU MD (ONC)

215494610

NIKHIL MULL MD

780.60, 461.9, 276.1, 250.00 .

215495740

KAI XU (HSP)Hypoxia

215197783TSAI DONALD E (ONC203.00, 787.01,

215494420CORRIE STANKIEWICZ A MD (HSP)


15/55

599.0, 041.4, 486, 472.31

215318058BRENDAN M WEISS MD (ONC)

9 and 10 PUL 7/10 PUL (hypoxia)=99232

MARISSA,WILCK B MD07/10=histry and exam full ,,,. Mdmd??? 11 and 12=== 07/11=IFD

16 and 17 =renal 07/11=99231

799.02, 458.0, 277.3, 728.87, 780.6007/13-d/C

GORAL SIMIN MD.

ADAM D COHEN MD (ONC)Dehydration

215339450.(ALL)

JAMES MANGAN MD (ONC)

07/14-D/C by Donald TsaiJINGMEI HSU MD (ONC)204.00, 530.81, 070.30

215492325 ADM :-GLUCKMAN STEPHEN MD ATT:- GARLAND,JOSEPH MD

Pyeloneph

KEITH HAMILTON W MD

GARLAND,JOSEPH MD

790.7 (bacteremia), 0471.49(ecoli), 584.9, V42.0

WARBURTON, KAREN M M.D.

215487853

ADM :-RANJEETA R BAHIRWANI MD (GAS)ATT:- HOTEIT, MAAROUF MD

Hematochezia (578.1)


16/55

578.9,

07/14=PX

215360696

SAVITZ JODI MD (HSP)CORRIE STANKIEWICZ A MD (HSP)hematuria

599.70(hematuria), 282.60 ( sickle cell anemia), 427.31,06/12=99233- hecth

215381965 (SOB) ICDS

ADM:- COLLMAN RONALD MD ATT:-KAREN C PATTERSON MD

518.81, 584.9, 042DINE CONSTANCE J (PUL)

215495187 (CP)PRENTICE MCCREA, NIKKISHA MD

427.31, 530.81, 272.4

215470503 (Aki) ADM:-RANJEETA R BAHIRWANI MD (GAS) ATT:- HOTEIT, MAAROUF MD

07/12(DIA) IC

07/13 (DIA) 12,13----07/14 , 19 , 20---07/15 ,26,27

07/14(Endo) IC

LAUREN FISHBEIN M MD

KHARLIP, JULIA MD

276.7,790.4, 414.00, 250.00

215551047

HOTEIT, MAAROUF MD (GAS)780.97 (AMS), 276.1 (HYPO), 571.5 (cirro), 572.2 (HE)

070 571.5

215762586

HOTEIT, MAAROUF MD (GAS)

215699267

Waxman adam j (ONC)

DAVID L BAJOR MD (ONC)GIANTONIO BRUCE J (ONC)=D/C786.09, 162.9, 250.00, 511.9


17/55

786.05, 780.96, 162.9

215735293 (DKA) ADM:-SCHWEICKERT, WILLIAM D. MD (PUL) ATT:-MILLER, JEAN C. MD (GIM)CORRIE STANKIEWICZ A MD (HSp)

250.11, 584.9,

215618762

PATEL, NEHA MD (HSP)

8-11=PUL visit

786.05, 428.0 (CHF), Interstitial Lung Disease 511,, 305.1

215555410

KAREN C PATTERSON MD (PUL)

07/17=EGD pX done,GI (07/15) =5

GI (07/16)=6

GI(07/18)=11

252=dx=

PACK MICHAEL MD

215791494

PRENTICE MCCREA, NIKKISHA MD8-11(RENAL )IC,07/22==D/C

215495161 (Dia)BRENDAN M WEISS MD (ONC)13-15=07/16

5-8 =renal IC 07/14=9925211-12 = Renal =07/15 HD16-17 = Renal =07/16 HD

21-22 = Renal =07/17 HDNICHOLAS TSOPELAS MD (PSY)

780.97, 202.80, 585.6, 250.00

07/18=D/C

215762586

HOTEIT, MAAROUF MD (GAS)


18/55

285.9, 790.99, 571.5, 428.0

215793417 (missing progess notes)

MILLER, JEAN C. MD (GIM)missing progress notes

215448285 (MM)TSAI DONALD E (ONC)

07/17=

Collen Scheeler

203.00, 783.0,530.81,

NASTA SUNITA MD

215857105

PERL ALEXANDER E MD (ONC) Add comment :-IGPF:-GP for TSU

KUCHARCZUK JOHN C MD TSU done surgery 39400. 07/23/2014

275.42, 202.80, 244.9, 427.31

ATT:-mato

07/22=99232

07/23=99232


19/55

07/24=D/C

215702277

TSAI DONALD E (ONC)204.00, 530.81, V58.11, 250.00

07/22=billable 99233 Elizabeth E. Umbro, CRNP

PX pending

215913239

Check for linking is rit r not and also check for risk

07/23=99221 no reminder ve

07/24=99238 D/C

780.60, 204.10, 287.5, 285.9,

215879422(pyeloneph)

CORRIE STANKIEWICZ A MDURO 07/22=IC , 5-8

07/23, URO =9

07/23 IV 99221

041.85, 790.7, 590.80, 584.9

215857246DAVID L BAJOR MD (ONC)07/22= 99232 (DOWNCODED)07/23=99233IC _07/23=99253 (Detailed history)GARLAND,JOSEPH MD (IFD)

288.00, 780.60

215846082

DIAMOND, JOSHUA (PUL)07/22=9923307/24=9923807/23=99233277.02, 250.00, 577.8

215793037CHARU AGGARWAL MD (ONC)07/21=99233156.1 790.4GINSBERG GREGORY MD=PX=GAS=07/22

VESSELIN TOMOV MD (GAS)


20/55

576.2 =07/21=9925207/22=UBT07/23=99231

215792179GARLAND,JOSEPH MD (IFD)

216068777HOTEIT, MAAROUF MD (GAS)

215911183SCHUSTER STEPHEN J MD (ONC)

RESHEF, RAN MD

Non billable PA-C NON billable CRNP

215857618

PATEL, NEHA MD (HSP)DAVID A PEGUES MDWARBURTON, KAREN M M.D.

TRU =SV:-07/23=9 ICD

07/23-IC renal -99255,

RENAL=07/24=SV, 12 and 13===14 and 15 SV 07/25

07/23,24=99233.

807.02, 511.9

595.9, 0414.04

215793417

216125874

PRENTICE MCCREA, NIKKISHA MDGOLDSTEIN IRWIN S MD


21/55

216070997

HOTEIT, MAAROUF MD (GAS)DAVID GOLDBERG MD (GI)

07/26=99223599.0(UTI) 572.2 (HE), 070.70 (hepc) 571.5(cirrhosis)

216085961

Initial consultation not coded, and check PDX diagnosis .

216146227

BELLINI LISA M MD (PUL)99221, 07/30======07/31====9923308/01=99238,CAP, 403.90, 585.9, 414.01.

216082646 RIMINI A VARGHESE MD (ONC)SOMNANG PANG DO (PMR)

781.99

Waxman, Adam216086589 HYPOGLYCEMIA

PRASAD, MEETA MD (PUL)

KAI XU (HSP)

216202798

PRENTICE MCCREA, NIKKISHA MDCellulitis

682.9, 174.9, 459.2, 493.90

216146227

BELLINI LISA M MD (PUL)

216144826 AKiDAVID GOLDBERG MD (GI)07/30=9923307/31=D/C715.9, V42.7

216116956

syncope

CAITLIN MARTIN KLINGER MD (HSP)SARA A VAN CALCAR MD (HSP)CORRIE STANKIEWICZ A MD

787.91, 161.1, 197.0, 198.3

216146508


22/55

HECHT TODD MD (HSP)JULES B LIPOFF MD (DERM)705.83

215447394 (ALL)

JINGMEI HSU MD (ONC)HIRSH, REBECCA L MD

DANIEL J LANDSBURG MD (ONC)

216231268

CAPRICE L CADACIO MD (ONC)

216085995

FRANK IAN MDCOPD EXHAB

07/28=99223

07/29, 30, =99233

07/31= TEBAS PABLO M MD (IFD) 99233

08/01=99233

215535446

TSAI DONALD E (ONC)

07/24=99233

216105884

JINGMEI HSU MD (ONC) adm

HIRSH, REBECCA L MD (ONC)

216231805

PRENTICE MCCREA, NIKKISHA MD (HSP)DizzenessCHECK APS under px section ++789.00, 787.01 255.4108/02=99232 (asked to swapna and sravanthi) IV down coded to sv as there is no linkage and exam.08/03=9923308/04=99238

216372021

Facial weekness

Iran frank

781.94, 719.4

351.0

PRUITT AMY MD


23/55

216262362

KIRSTIN S KNOX MD (HSP)CORRIE STANKIEWICZ A MD (HSP)08/04/2014=52332= WEIN ALAN J MD (URO) check it in epic

GOLDSTEIN IRWIN S MD08/01/=

DAVID PRICE MD

Marandola, Elizabeth

DELISSER HORACE MD

216372856

216236887

DELISSER HORACE MD (PUL)DAVID GOLDBERG MD (GI)BERNS JEFFREY

DELISSER HORACE MD

Completed till 25 th pageKY, BONNIE MD (cardio )

28 th page cardio ATT =99251

Pallliative care 08/05

Check for gastro ,, that is not an consultation (transfer note on 24 and 25 page )

Dialysis

216370843


BARTON TODD M.D.

216311250

DAVID GOLDBERG MD (GI)

216365603 PRENTICE MCCREA, NIKKISHA MD

216540080


289.83,

216492746


24/55


NITKIN, APRIL CRNP

216374597


11 th to 14 th page IC renal=

21 and 22 renal SV=08/05

15 and 16 th CC 99291 =08/04

19 th SV sug

25 and 26 = palliative care =08/05

27 28=CC 08/05

32 33= 08/06=sV

34 35 renal SV=08/06

39 th page palliative care ask do we need to code

18 and 19 , 25 and 26

NSCLC pdx and thrmbo

JOSE PASCUAL LOPEZ

729.99

Pall iat ive cd

40, 41 Sv 08/07=

42 43 renal sv

08/08=99238=Amanda

216602054

216576076


25/55

DAVID GOLDBERG MD (GI)

216492803

ADAPPA,NITHIN D MD

216619421

TEITELBAUM, URSINA

216650434



719.17, 724.5, 286.0, 785.0

216412744

TEITELBAUM, URSINA (ONC)

216600280

JOHN MCGREEVEY

HINES JANET MD

215782196

965.09

216639155

pancreatitis

CAPRICE L CADACIO MD

If sepsis and uro sepsis found code only for urosepsis,

216595852

216655235

JOHN MCGREEVEY153.9,


26/55

216395329

KARAKOUSIS, GIORGOS C MD (SON) surgical oncology

KOVACH, STEVE (plastic ) shd code

RIMINI A VARGHESE MD (ONC)729.5, 172.9, 475.1,7 and 8 th, 9, 10, 13, 17 page dout

216653321

HINES JANET MD (IFD)

216656126

28003 90day ( ALBERT D'ANGELANTONIO DPM (PLS) on 08/13/2014

EMMANUEL S. KING, MD (GIM)707.15, 790.7, 070.70, 401.9

216655086

08102014=6.7.19.18

GOLDSTEIN IRWIN S MD (URO)

MARIETTA AMBROSE MD (CVM)

591

MANDEEP DAGLI

NO ANN CUN

Endoscopist: Michael Rajala, M.D

Exam Date: 08/04/2014

216653222

43260 Px 0 days by 08/12= Ginsberg Gregory.

43255, 08/04, Rajala Michael

216375818

216692949

Broncoscopy=08/11= anthony lanfranco (PUL)

8,9,12

99252.


27/55

216706871

216649220

NUZHAT AHMAD, M.D. (GAS) =08/14=44366

19, 20, 10, 13 no sx,

216860454

CHEK IN EPIC

729.81, 787.3, 785.6,

216268633

Riff resident

AMY CLARK MD (ONC)

216052672

DANIEL J LANDSBURG MD

SHANNON A CARTY MD

216767782

EMMANUEL S. KING, MD (GIM)

MATTHEW GARIN T MD

216805152

MATTHEW DENKER MD

216813198 BERNIE Y SUNWOO MD (PUL)10 and 11 th page remut sv =99233, (08/15 and 16,18)

279.49

PENDING REMUT CONSULTS

216944514

VAUGHN DAVID MD (ONC)

LEE, JAMES C MD (PUL)

217004680

DAVID PRICE MD ( HSP )

216938060


28/55

Renial SV 7 and 8

DIA SV 11 and 12

216830663

TWYMAN SAINT VICTOR CHRISTINA A MD (GAS) =EGD = 08/14SHASHATY,MICHAEL MD (PUL)

CVM216943896 216944464

JOHN MCGREEVEY (HSP)

831.00

216877698

216946444

JENNIFER H HAN MD (IFD) 217082264

217194333

217118811

216983991

216609273

216977589

217209032

217174376

MAKAR, GEORGE

217116633

217227513

625.9, 789.09, 707.00

217220930


29/55

217188848

MATTHEW GARIN T MD (HSP)CONSTANTINE CHAKNOS M MD

217225277

217285727

GINSBERG GREGORY MD (GAS)=08/27=43238 = o dayGREENBLATT, JEFF MD (HSP)DOMCHEK SUSAN MD (ONC)GI 08/26=5

217221656

CHIESA FUXENCH ZELMA CHARLOTTE MD (DERM)UBT for IC REMUT 08/23/2014

ROBERT G MICHELETTI MD (DER)CHIANG, MARK

087.9, 785.6,

5-8=hematology IC:

11-12 remut =08/24 =

26-27-remut =08/26

30,31= remut =08/27

08/25 and 26 =99233= history and examination

08/27=99232, 08/28 = D/C=99238

217400607

729.89

217362021

217263831

790.7, 041.12,


30/55

217397613

HILLARY LANE BOWNIK MD (GAS) 08/29=45378, 45380

99254, 789.00, 787.02, 309.0

08/28=99223

Gas =99253 (08/27) but there is plan for EGD and px done on 08/29 = check it with verifier

08/29=232 (GAS)

ADAM D COHEN MD (ONC)

07/07=D/C=99238

217502774

217485384

217492836

43255 -09/2/2014-ginsberg Gregory

217064007


31/55

AHN, JAIMO MD (ORT)BILLABLE MARANDOLA ELIZABETH6-9Dot on _14 and 10-12 pages 17,18., 21, 22

SOMNANG PANG DO (PMR)785.2

6-9 (8/23,24)

23,24 (transfer note) but no attending 08/26

2-4(8/27)

6-10-08/28,29)

217555525


32/55

HAAS, NAOMI S MD

217547282IV= his- com, Mdm-high=09/309/04=9923309/05=D/C=99238584.9, 428.22, 250.00, 285.9

217593112217698176217617663217647017

BLOOM ROY

217566811217013079217755612

217527425

217697319

217756859

217753476

217707233

217261306

217760430

217752338

TWYMAN SAINT VICTOR CHRISTINA A MD

MAKAR, GEORGE (GAS ) 09/06 =EGD

217754052 217760273 , 21777319

Heart Failure with Preserved Ejection Fraction (HFPEF)

UMSCHEID, CRAIG A., MD (GIM)

NICHOLAS TSOPELAS MD (PSY)217953357217939067


33/55

217744558

217827916

217827452

217812934

JAFFE DAVID L MD AHMAD NUZHAT MD (GAS)=09/11217798216

217981911MRINALINI SARKAR MD

217642885

HIRSH, REBECCA L MD

217859737

217892902

218009779


34/55

218070466

217986175

IV 99233

6,7 and 8 CV sv

9 and 10 , 11=09/12

218074096

BURNHAM ALISA MD09/14= vacc

218069773

218070631

218068783

218036558

217870627

218077057

217954033

217959883

217741091

218077271

558.9

217432576

10-13= palliative care = 08/29

18-21= check ehere to code r not== no need to code

Check ref md for palliative care and sleep medicine service 08/29 and 09/04 service.

Doughty on page number 22 28 on set 2 Progness notes, === no need to code

11 and 12

31 and 32

218260026

218146308

218307348


35/55

218076448

218260992

218012880

218349837

Manju.ezhumalai@ omegahms.com

218197392

218142273

218340380

217707035

218012682

218403113

218439133

218495499

218419051

218377366

218545210

218609149

218448977


36/55

16


37/55

218555102

218609677

218497743


38/55

218261248

218367656

218374470

218610295

218666719

09/29= vaccine

DEMARCO,MARIO MD09/28= circum.

218644088

09/28, VACCI, 09/27= px


39/55

218667691

09/29=Vacc

218566141.

09/26=VACC

09/26=PX

218625194

218610154

218634196

218534321

218658690 missed 25 modifier

218496992

26 th cc billed

218734616

Vacc:-09/30

Circum:- 10/01

218781476

10/01= vacc

218735167

10/01= VAC


40/55

218797118.

10/01=VACC

218793422

218863092

10/03= vacc, px

218860148

10/02= vacc, px russel

218864223

10/03

218899047

10/04= vacc

218670232

09/3= VACC

218671297

RANJEETA R BAHIRWANI MD218843474


41/55

218670232

09/30= VACC

218862573

Missing DOS

10/02= VACC

218847798

10/03 = VACC

218922351

218975987

10/04= VACC

487826= SHD ADD vac icd

218922179

10/05= vacc

10/03= snY

218976662


42/55

10/04= VACC

10/04= PX NICKLIN

487845

Vavd =vacuum assisted delivery and forceps iicds

218922617

10/04= vacc

218840694

10/01= vac

218978007

10/05= v

218980664

10/05=v

10/05=px

218979120

10/05- va

10/05- px

218922542

10/05=v

10/05=px

SCHUTTA MARK HCHRISTINA MITCHELL

218976126

10/04= va

10/05= nik px

218977116

10/04= vac

10/05= px

218980656

10/05= VA


43/55

10/05= PX

218921874

10/03 =va 10/05- px

218860296

10/02= v

218821561

218977066

10/04= v

218906917

218840694

10/01= v

218922591

10/06=vv

218843474

DOUGHT FOR 10/03 Dos abt spec HEATHER CATES CNM (OBS)

218922906

218977306

218937839

218922559

218922575

.

218670729


44/55

218733030

218670729

REDDY K RAJENDER MD (GAS)

218982702

10/06=

218990069

10/07=v

10/07= px=posch

218984021

10/07= vac

10/06=posch

218984526

10/08=vac

218984179

10/06=

10/07= px posch

219051333

10/07=Vac

219175280

219102698

219051093


45/55

219087139

218667907

218733451

SCHWAB RICHARD MD (PUL)

219289909219049782

219031483

219153006. 219233642

219176437

219033323

218973453

219230713

219083377

219049055

219286053

219244821

218667907

219232834

219266337


46/55

218982421

219027044

219030733.

219001189.

219176643

218983908

218978684

218919779

219269067

219285584

219175827

219258136

219282607

219339548219332774

219371160

219299304

219401819


47/55

219285550

219290881

219538495

219471457

10/15=px

218715946

219581602

219368794

219053875

219534668

219584317

219592484

219275668

MDS , myelodysplastic syndrome ...

219594670

219556471


48/55

218404046

219662311

219723154

219654466

219594597

219354455

PSY0020

Delirium and atrivan can be taken as risk in PSY charts

Malignant neoplasm, Diabetic uncontrolled, flare, exhabiration,=high

c/p:-chest pain, SBO:-small bowel absto, PSbo:-Partial bowel absto, C/B:-complicated by, P/W:- presents with

Cc= Time, condition and management Morning stable afternoon cc code both and add modifier 25 And if afternoon (af) stable morning cc we dont code both the services only cc code should be given.


49/55

Same dos same spec add all cc time and code add modifier 25 to first Same dos diff spec can code both without modifier

Resolved ICD dont code SQH is high med

Beside cxt result in attending note (My read) if mentioned then take (take visuvalization)in mdm( mostly in subvisit)

{ C/B=complicated by, H/o=history of, s/p=status post, sx=symptoms, USOH:- usual stage of healthm, DOE:-Dypnea onexertion

medicare=99221-99223 AI for consul op medicare- new /estab=chek spe 99201-99205 and 99211-99215 ip- m -99221- 99223 = dont give consultation code only give Ai to intal addmsn visit

missing At.phy, hence down coded to subsequent

Pall iat ive care services shou ld be coded even there is at tending l inkage

PE:-high risk,

AKI, all anticoagulants, ESRD, sepsis, hematemesis, sirs, CAD,

GI bleed, CAD, Flare, enoxaparin, ELECTROLYTES HIGH OR LOW ALWAYS HIGH, Delirium, Bacteremia, BKA, CHF, TRNSPT(EXPT

STEM CELL TRANSPLANTSSSS), Hypernatremia, acute PE. Meningitis, hyperkalemia, cellulitis, HIV, hypokalemia, TB

(TUBERCULOSIS), GI bleed,Hemophilia along with condition (hemophilic arthopathy)

Suicidal ideations

INTUBATED< SEDATED< AMS< UNBLE TO OBTAIN= HIS comprehensive,

Heparin, enxoparin, delteparin, SQH, vanco, warfarin, lovenox, Coumadin. LMWH

Ser :- OBS NAME:-__________ BA:-10467,

HIGH RISK as per HUP

Consider high risk if any high risk medications eg: SQH, Coumadin, Warfarin are given.

We are considering CVA, hemiplegia, paraplegia, multiple fractures andweakness except generalized weakness as high risk for PMR. Also braindamage or spinal cord damage.

We should give 781.99, 729.89 (weakness in limbs), hemiparesis, paralysis,


50/55

fractures as PDx for PMR charts High risk medications eg: SQH, Warfarin Coumadin are there, consider as

high risk. Foot drop, facial droop, OLD CVA, etc are considered as high risk.

On the day of ECT, consider high risk for E/M. If any high risk medications eg: SQH, Warfarin Coumadin are there, consider

as high risk. Suicidal ideation, homicidal ideation, pregnancy, delirium, AIDS, etc are alsoconsidered as high risk.

Examples of High Complexity Medical Decision Making :

Any new problem with additional workup requiring review of labs and radiology reports, ordering of new tests, ECGinterpretation, and the decision to obtain information from other sources (for example, a patient's family or old records)

A COPD exacerbation and uncontrolled hypertension A severe pneumonia with workup Acute renal failure with workup Worsening severe chronic kidney disease and uncontrolled hypertension Stable severe chronic kidney disease, stable diabetes, but uncontrolled proteinuria ( need to confirm) severe chronic kidney disease( ESRD) if only not on dialysis , Mental status changes with workup Cardiac catheterization with "risk factors" for chest pain . DDX: GI bleeding Pain with workup requiring IV narcotics ( need to confirm) Therapy with heparin, warfarin, gentamicin , or other medications requiring monitoring for toxicity and any new problem with

workup Any "major surgery" with "risk factors" Any emergency "major surgery"

Alteplase, Ardeparin, Dalteparin, Danaparoid, Enoxaparin, Fondaparinux, , Warfarin

Coumadin initiation

________________
http://www.medindia.net/doctors/drug_information/alteplase.htmhttp://www.medindia.net/doctors/drug_information/alteplase.htm


51/55

PE:-high risk, AKI, LMWH, all anticoagulants, Coumadin, heparin, deleparin, ESRD

Suicidal ideation, homicidal ideation, pregnancy, delirium, AIDS, etc are alsoconsidered as high risk.

HIGH RISK as per HUP

Consider high risk if any high risk medications eg: SQH, Coumadin, Warfarin are given.

We are considering CVA, hemiplegia, paraplegia, multiple fractures andweakness except generalized weakness as high risk for PMR. Also braindamage or spinal cord damage.

High risk medications eg: SQH, Warfarin Coumadin are there, consider ashigh risk.

Foot drop, facial droop, OLD CVA, etc are considered as high risk.

On the day of ECT, consider high risk for E/M. If any high risk medications eg: SQH, Warfarin Coumadin are there, consider

as high risk. Suicidal ideation, homicidal ideation, pregnancy, delirium, AIDS, etc are also

considered as high risk.

AKI, LMWH, all anticoagulants, Coumadin, heparin, deleparin, ESRD, sepsis,SIRS. Lovinox, CHF, CAD

SQH,

Pul Emboli, SOB,

If one element missing in derm consult chart then take pe as detail

DAVID PRICE MD

Sign (1) PRENTICE MCCREA, NIKKISHA MD)

2)Ralph verdino


52/55

Hecht, Todd E (HSP)

Sleep Medicine : patcom-216189326 (Page 4 of consults) Pack, Allan MD NPI# 1568555241 Provider #012575

IFD: Patcom-215739972 (page 8 of progress notes 16-20 days) Cluzet, Valerie MD- NPI#1619136660 Provider # R08441

1. Neuro: patcom-216449118 (Page 23 of progress notes 1-5 days). Becker, Danielle MD- NPI# 1134381759 EPICprovider # R01317


53/55

2. OBS- Patcom-216110892 (page 2 of operative note)

1 chart is pending for this provider detsils This is a resident

3. GIS: Patcom-216603284 (page 4 of progress reports) Lee, Major Kenneth MD- NPI#1235286220 EPICprovider # R08074

5 charts are pending for this provider details.

4. Neonatal ICU-Concurrent care service- MRN- 444775332 (8/3/2014)

-Taha, Dalal DO-NPI#1346537248 EPIC provider #17507764

MATTHEW GARIN T MD

Kirstin Knox

ROSENBACH, MISHA A MD

DAVID L BAJOR MD

JOSHUA M BAUML MD


54/55

CAPRICE L CADACIO MD

WEINRIEB ROBERT MD

AMY CLARK MD (ONC

NASTA SUNITA MD

If found in this way , that is same resident linkage

DAVID PRICE MD

IINF: Two physicians billed the same day for DOS ----------IDMN:EPF history, hence downcoded to 99252;Medical student is not involved.

IINF: Time based coding for DOS:----

1)FOR PALLIATIVE CARE SERVICES SELECT ATTENDING AS NINA O CONNOR MD COMES UNDER SERMED AND BA# AS 10425

SER:-MED, PALLIATIVE CARE BA 10425 BA # 9086, SSB: - NO, SUB PROVIDER NAME ERIN CARTON CRNP, IF NAME ID NOT FOUND THEN IT IS NON-BILLABLE CRNP.

IN PALLIATIVE CARE PDX SHOULD BE PAIN (IF PAIN IS PRESENT) AND FALLOWED BY REASON.

2) RENAL

DIALYSIS:-IC+HD-==CODE IC AND HD= e/M WITH 25, GC, AND ENTER HEMODIALYSIS CODE 90935 AT BUTTOMCOLUMNS, billing area RTP for initial V42.0SV+HD == CODE ONLY HDDC+HD== CODE ONLY HD

IN SUBSIQ WE HAD TO SEE NOTE PT SEEN ON DIALYSIS, LINKAGE, THEN CODE ONLY HD I F NOT ( ANYTHING M,IS)CODE SV

3) IF IN MDM ESRD IS THERE AND PATENT HAS HTN CODE COMBUINATION CODE


55/55

4)CODE BILLING AREA FOR IFD AS IDP IF PATIENT HAS AIDES /HIV AND USE DIAGNOSIS AS v08 FOR HIVAND 042 FOR AIDS.(NOT PRIMARY)

5) when scopy is planed procedure prior 1 day then no need to code on the day of procedure.

For plastic surgery SER:-sur, DIV:-plastic surgery, B Area :-10123, BA # 9047.

QUESTIONS:-1. Can we take medications (from ED note) in HPI as MF ?ANS:- NO (dont consider) 2. estb prob calculation ?3. Addition of comment when decreasing level in IV?4. Can we consider this as review of old records and give two points as per MDM b tableANS:-YES

History elements ???\

ANS :-can take

HUDOCK,KRISTIN MDROGER,COHEN B MD786.6,

Documents

Hpi Elements