hpi elements
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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
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Radiation oncology format dont code ( Nicole ross ) crnp)
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
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.. 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
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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 -
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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.
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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.
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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
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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
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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)
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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.
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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
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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
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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
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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
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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)
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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)
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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
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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)
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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
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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)
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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
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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
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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
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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
DANIEL J LANDSBURG MD (ONC)
BARTON TODD M.D.
216311250
DAVID GOLDBERG MD (GI)
216365603 PRENTICE MCCREA, NIKKISHA MD
216540080
DANIEL J LANDSBURG MD (ONC)
289.83,
216492746
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DANIEL J LANDSBURG MD (ONC)
NITKIN, APRIL CRNP
216374597
CAITLIN MARTIN KLINGER MD
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
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DAVID GOLDBERG MD (GI)
216492803
ADAPPA,NITHIN D MD
216619421
TEITELBAUM, URSINA
216650434
DANIEL J LANDSBURG MD (ONC)
CAITLIN MARTIN KLINGER MD
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,
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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.
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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
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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
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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,
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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
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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
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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
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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
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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
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218076448
218260992
218012880
218349837
Manju.ezhumalai@ omegahms.com
218197392
218142273
218340380
217707035
218012682
218403113
218439133
218495499
218419051
218377366
218545210
218609149
218448977
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16
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218555102
218609677
218497743
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218261248
218367656
218374470
218610295
218666719
09/29= vaccine
DEMARCO,MARIO MD09/28= circum.
218644088
09/28, VACCI, 09/27= px
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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
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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
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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
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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
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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
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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
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219087139
218667907
218733451
SCHWAB RICHARD MD (PUL)
219289909219049782
219031483
219153006. 219233642
219176437
219033323
218973453
219230713
219083377
219049055
219286053
219244821
218667907
219232834
219266337
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218982421
219027044
219030733.
219001189.
219176643
218983908
218978684
218919779
219269067
219285584
219175827
219258136
219282607
219339548219332774
219371160
219299304
219401819
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219285550
219290881
219538495
219471457
10/15=px
218715946
219581602
219368794
219053875
219534668
219584317
219592484
219275668
MDS , myelodysplastic syndrome ...
219594670
219556471
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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.
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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,
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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 -
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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
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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
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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
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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
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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,