Progress note: Admitted through ED for generalized abd. pain, dehydration
Old records: Requested, reviewed
Heart: RRR, carotid pulses
Lungs: CTA
Abd: soft, NT, BS normal, no hemorrhoids
RLQ tenderness, guarding
A/P: RLQ abd. pain, dehydration
Additional “query” diagnosis: ETOH abuse or intoxication on admission based on blood alcohol levels upon admission, but not documented. If ETOH abuse is confirmed, documented and coded, it will have the following impact:
E&M Impact
Documented as noted in PN: 99231, $39
Documented with additional queried diagnosis: 99232, $61
