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Cardiology Pro Fee Impact Example

Thursday, 05 February 2009 10:23 CDMatters.com Staffer Clinical Documentation Samples
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Inpatient Subsequent Hospital Visit
S: 68 y/o female admitted with palpitations/atrial fibrillation, now c/o of painful urination
O:  VS:  T 99/BP 110/82, Lungs CTA 
A/P:   A-Fib, Check UA
CV: irregular rate,  EKG indicates A-Fib, Abd - tender

UA +, but no UTI documented, the addition of documentation of a UTI impacts the reimbursement in the following manner:

E&M Impact
A-Fib only
(Hx: Prob. Focused/Exam: Expanded/MDM
Straightforward) = 99231 = $39

A-Fib/UTI
(Hx: Prob. Focused/Exam: Expanded/MDM
Moderate = 99232 = $61

 
Comments (1)
Pro fee examples
1 Monday, 16 November 2009 15:44
Kristine Cilona
These are great examples! As CDI nurses we are always hearing from the physicians, "What's in it for me?" Now, I can actually show them. I have never seen a course offered for CDS nurses on this. It would really be beneficial to help us understand it and then show the physicians examples of how improved documentation affects them and the hospital.
Thank you so much,
Kris Cilona, RN CDS, Mercy Medical Center


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