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Rajitha Mannem <Rajitha.Mannem@sutherlandglobal.

com>; Shravya Vaddiraju


<Shravya.Vaddiraju@sutherlandglobal.com>; Laxmi Kanth Singh G <LaxmiKanthSingh.G@sutherlandglobal.com>; Sri
Lakshmi Sravanthi Tirumala Raju <SriLakshmiSravanthi.TirumalaRaju@sutherlandglobal.com>; Arun Kumar Basa Govind
<ArunKumarBasa.Govind@sutherlandglobal.com>; Vamshi Mary Thumma
<VamshiMary.Thumma@sutherlandglobal.com>; Pavitra Swapna Namburi
<PavitraSwapna.Namburi@sutherlandglobal.com>; Vishnu Venamma Puchalapalli
<VishnuVenamma.Puchalapalli@sutherlandglobal.com>; Theja Katipally <Theja.Katipally@sutherlandglobal.com>;
Sravani Mallampati <Sravani.Mallampati@sutherlandglobal.com>; Neha Reddy Ponagandla
<NehaReddy.Ponagandla@sutherlandglobal.com>; Ramesh Edunoori <Ramesh.Edunoori@sutherlandglobal.com>;
Koushik Adlluri <Koushik.Adlluri@sutherlandglobal.com>; Swetha Varanasi <Swetha.Varanasi@sutherlandglobal.com>;
Chaitanya Pamidi <Chaitanya.Pamidi@sutherlandglobal.com>; Pavan Kumar Medicherla
<PavanKumar.Medicherla@sutherlandglobal.com>; Siri Mamatha Chennuru
<SiriMamatha.Chennuru@sutherlandglobal.com>; Gazal Pandey <Gazal.Pandey@sutherlandglobal.com>; Annapurana
Yellakarri <Annapurana.Yellakarri@sutherlandglobal.com>; Vani Sharma <Vani.Sharma@sutherlandglobal.com>;
Pratyaksha Boora <Pratyaksha.Boora@sutherlandglobal.com>; Sandeep Sikar
<Sandeep.Sikar@sutherlandglobal.com>; Swathi Katta <Swathi.Katta@sutherlandglobal.com>; SumanReddy Gottam
<SumanReddy.Gottam@sutherlandglobal.COM>; Manjeerabai U <Manjeerabai.U@sutherlandglobal.COM>; Analtej
Ambati <Analtej.Ambati@sutherlandglobal.com>;
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


Radiation oncology format dont code ( Nicole ross ) crnp)

adllurikoushiksharma@gmail.com
georgevelankanni.l@teamhgs.com
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


.. 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
VENKAT -9866045717=FOR ACCOUNT LOCK
GSD :- 582986, 6400, 9885457586, VENKAT -9866045717
SOME can be taken as history element
Pratyaksha Boora <Pratyaksha.Boora@sutherlandglobal.com>; Keerthi Madeti <Keerthi.Madeti@sutherlandglobal.com>;
Maheswari Hanumantha Kari <MaheswariHanumantha.Kari@sutherlandglobal.com>; SushmaReddy Masku
<SushmaReddy.Masku@sutherlandglobal.COM>; Vani Sharma <Vani.Sharma@sutherlandglobal.com>; Analtej Ambati
<Analtej.Ambati@sutherlandglobal.com>; Annapurana Yellakarri <Annapurana.Yellakarri@sutherlandglobal.com>; Gazal Pandey
<Gazal.Pandey@sutherlandglobal.com>; Sushma Bangari <Sushma.Bangari@sutherlandglobal.com>; Sandeep Sikar
<Sandeep.Sikar@sutherlandglobal.com>; MridulaPavani G <MridulaPavani.G@sutherlandglobal.COM>; Pavitra Swapna Namburi
PavitraSwapna.Namburi@sutherlandglobal.com; Raja.Chinni@sutherlandglobal.com
Sri Lakshmi Sravanthi Tirumala Raju <SriLakshmiSravanthi.TirumalaRaju@sutherlandglobal.com>;

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 elements 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 can 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.
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, BP
home shows good control
Duration When did the symptoms start?
How long has the patient had the symptoms?
Today, weeks, months, longstanding
years
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 any
activities?
After surgery, in a motor vehicle
accident, when elevated, at work
Modifying factors What has the patient tried to relieve the
symptoms?
With ice, using meds, with OTC lotion
Associated signs and
symptoms
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 of
the symptom(s)
How it looks or
feels

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 feeling
well or okay.
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 of
last night, the symptoms have lasted for 24 hours, or it could be a longer time, such as longstanding, months, years. Any
description about the duration of the length of the patient's symptoms, illness or condition can be used as an element of
duration.
Timing: That is, under what circumstances do the symptom occur? Is it intermittent, continuous, constant, upon
awakening, 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 a
motor 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 without
physician direction, which the patient has used to try and improve their symptoms. It could be that the patient has been on
antibiotics 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's
chief 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 will
use a negative response in associated signs and symptoms.

Past, Family & Social History
Past medical, surgical history, hospitalizations, operations, immunizations, medications, dietary feeding status, allergies
Family family health status/cause of death, diseases related to CC, hereditary diseases or those that place pt. at risk
Social 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
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 MD
Att:- MYERS JENNIFER S MD (HSP)
SCHUTTA MARK H
PRASAD, MEETA MD
LAUREN FISHBEIN M MD

UMSCHEID, CRAIG A., MD
PRICE, RAYMOND MD
PATEL, NEHA MD
SAVITZ JODI MD
================13,5
PATEL, NEHA MD
Admit:-MIGNOTT HAROLD MD (HSP)
ATT:-MYERS JENNIFER S MD
MAKAR, GEORGE (GAS)
VANDANA KHUNGAR MD (GAS)
JUNKO TAKESHITA MD (DER)
ALBELDA STEVEN M MD (PUL)
DINE CONSTANCE J

MYERS JENNIFER S MD
SMITH,KERRI A MD
JINGMEI HSU MD (ONC)

Shah and Shaffer (onc) non billable
SAVITZ JODI MD
MYERS JENNIFER S MD
HECHT TODD MD (HSP)
99223 AND 99239
CONSULT ASK ARUN
PRUITT AMY MD
ARTURO LOAIZA-BONILLA MD(ONC)
99232
VANDANA KHUNGAR MD (GAS)
GROSSMAN ROBERT A MD
HECHT TODD MD (HSP)
BEN STANGER, MD.
HECHT TODD MD (HSP)
SHASHATY,MICHAEL MD (PUL

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)






Maus,Douglas MD
NPI#1447315650 EPIC # 17146578




GYN: Added one more provider. Patcom-216076143 (Page 3 of progress notes). Two charts are pending for this
provider 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.
KOBRIN
SIDNEY M MD

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

1) 214873426
DLBCL
JINGMEI HSU MD (ONC). DANIEL J LANDSBURG MD
2) 215183122
Asthma exhab
KAI XU

3) 215204753
Hypokalemic paralysis
MILLER, 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


JAMIE E SENGER CRNP

4)215200462
UMSCHEID, CRAIG A., MD
IDDM
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
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 bleed
07/09- sigmoidoscopy done by Gary Lichtenstein
07/09/2014=99223,
07/10/=99238

)215247810
BRENDAN WEISS MD
Cut t cell lymphoma
780.60,202.80, 356.9,705.83

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

No D?C ???/

215264682
HECHT TODD MD (HSP)

215264682

GORAL SIMIN MD
10=231 and 11=D/c
GLUCKMAN STEPHEN MD
7 and 8 07/10 renal
12 and 13 07/11 Renal
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 writings, IC 07/07

415.19, 706.1, 300.00, 793.19

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



12 and 13
th
page IFD 99231 07/10
14
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)
SIRS
07/07=99223

215420599
SIRS
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 acidosis
07/10==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
17, 18 07/10 normal
HAAS, NAOMI S MD (ONC)
SCHUSTER JAMES M MD (NSU)

15 and 16 =07/10,PUL, 23 and 24 07/12 PUL 07/09= intial
14 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, 345.9
DINE CONSTANCE J
07/09/2014= PUL

) 215389331

DINE CONSTANCE J (PUL)
LAUREN FISHBEIN M MD

786.09, 494.0, 553.3, 327.23
215378482
SARA A VAN CALCAR MD (HSP)
Meningitis
07/10=99223
07/11=99232, 07/12=-99239
322.9, 288.50, 787.01
KEITH HAMILTON W MD

214373047
AML
LUGER SELINA MD (ONC)
Non billable CRNP
07/07=99223
DANIEL 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

215197783
TSAI DONALD E (ONC
203.00, 787.01,

215494420
CORRIE STANKIEWICZ A MD (HSP)
599.0, 041.4, 486, 472.31


215318058
BRENDAN M WEISS MD (ONC)

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

MARISSA,WILCK B MD
07/10=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, 780.60
07/13-d/C

GORAL SIMIN MD.




ADAM D COHEN MD (ONC)
Dehydration

215339450.(ALL)
JAMES MANGAN MD (ONC)

07/14-D/C by Donald Tsai
JINGMEI 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)
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, 042
DINE 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/C
786.09, 162.9, 250.00, 511.9

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 MD
8-11(RENAL )IC,
07/22==D/C

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


5-8 =renal IC 07/14=99252
11-12 = Renal =07/15 HD
16-17 = Renal =07/16 HD
21-22 = Renal =07/17 HD

NICHOLAS TSOPELAS MD (PSY)


780.97, 202.80, 585.6, 250.00


07/18=D/C

215762586

HOTEIT, MAAROUF MD (GAS)

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
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 MD
URO 07/22=IC , 5-8
07/23, URO =9
07/23 IV 99221
041.85, 790.7, 590.80, 584.9

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


288.00, 780.60
215846082
DIAMOND, JOSHUA (PUL)
07/22=99233
07/24=99238
07/23=99233
277.02, 250.00, 577.8

215793037
CHARU AGGARWAL MD (ONC)
07/21=99233
156.1 790.4
GINSBERG GREGORY MD=PX=GAS=07/22

VESSELIN TOMOV MD (GAS)
576.2 =07/21=99252
07/22=UBT
07/23=99231

215792179
GARLAND,JOSEPH MD (IFD)


216068777
HOTEIT, MAAROUF MD (GAS)

215911183
SCHUSTER STEPHEN J MD (ONC)


RESHEF, RAN MD




Non billable PA-C NON billable CRNP




215857618
PATEL, NEHA MD (HSP)
DAVID A PEGUES MD
WARBURTON, 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 MD
GOLDSTEIN IRWIN S MD

216070997
HOTEIT, MAAROUF MD (GAS)
DAVID GOLDBERG MD (GI)


07/26=99223
599.0(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====99233
08/01=99238
,CAP, 403.90, 585.9, 414.01.


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

781.99


Waxman, Adam
216086589
HYPOGLYCEMIA
PRASAD, MEETA MD (PUL)
KAI XU (HSP)

216202798
PRENTICE MCCREA, NIKKISHA MD
Cellulitis
682.9, 174.9, 459.2, 493.90
216146227
BELLINI LISA M MD (PUL)

216144826 AKi
DAVID GOLDBERG MD (GI)
07/30=99233
07/31=D/C
715.9, 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
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 MD
COPD 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)
Dizzeness
CHECK APS under px section ++
789.00, 787.01 255.41
08/02=99232 (asked to swapna and sravanthi) IV down coded to sv as there is no linkage and exam.
08/03=99233
08/04=99238


216372021
Facial weekness
Iran frank
781.94, 719.4
351.0
PRUITT AMY MD

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 MD
08/01/=
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
page
KY, 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
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

Palliative cd
40, 41 Sv 08/07=
42 43 renal sv
08/08=99238=Amanda


216602054
216576076
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 MCGREEVEY
153.9,
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.
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

Renial SV 7 and 8
DIA SV 11 and 12
216830663

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

CVM
216943896
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
217188848
MATTHEW GARIN T MD (HSP)
CONSTANTINE CHAKNOS M MD

217225277
217285727
GINSBERG GREGORY MD (GAS)=08/27=43238 = o day
GREENBLATT, 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,





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

AHN, JAIMO MD (ORT)
BILLABLE MARANDOLA ELIZABETH
6-9
Dot 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
HAAS, NAOMI S MD

217547282
IV= his- com, Mdm-high=09/3
09/04=99233
09/05=D/C=99238
584.9, 428.22, 250.00, 285.9

217593112
217698176
217617663
217647017

BLOOM ROY

217566811
217013079
217755612
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)
217953357
217939067





217744558
217827916
217827452
217812934
JAFFE DAVID L MD
AHMAD NUZHAT MD (GAS)=09/11
217798216
217981911
MRINALINI SARKAR MD
217642885
HIRSH, REBECCA L MD

217859737

217892902
218009779
218070466
217986175
IV 99233
6,7 and 8 CV sv
9 and 10 , 11=09/12
218074096
BURNHAM ALISA MD
09/14= 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
218076448
218260992
218012880
218349837
Manju.ezhumalai@omegahms.com
218197392
218142273
218340380
217707035

218012682
218403113
218439133
218495499
218419051
218377366
218545210
218609149
218448977




16
218555102




218609677

218497743

218261248
218367656
218374470


218610295
218666719
09/29= vaccine
DEMARCO,MARIO MD
09/28= circum.
218644088
09/28, VACCI, 09/27= px
218667691
09/29=Vacc
218566141.
09/26=VACC
09/26=PX
218625194
218610154
218634196
218534321
218658690missed 25 modifier
218496992

26 th cc billed
218734616
Vacc:-09/30
Circum:- 10/01
218781476
10/01= vacc
218735167
10/01= VAC
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 MD
218843474


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
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 H
CHRISTINA MITCHELL

218976126
10/04= va
10/05= nik px
218977116
10/04= vac
10/05= px
218980656
10/05= VA
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

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




219087139
218667907
218733451

SCHWAB RICHARD MD (PUL)



219289909
219049782
219031483
219153006. 219233642
219176437
219033323
218973453
219230713


219083377

219049055

219286053
219244821
218667907
219232834
219266337
218982421
219027044
219030733.
219001189.
219176643
218983908
218978684
218919779
219269067
219285584
219175827
219258136
219282607
219339548
219332774
219371160
219299304

219401819



219285550
219290881
219538495
219471457
10/15=px
218715946

219581602
219368794
219053875
219534668
219584317
219592484
219275668

MDS, myelodysplastic syndrome ...
219594670
219556471

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.

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

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

Palliative care services should be coded even there is attending linkage
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 and
weakness except generalized weakness as high risk for PMR. Also brain
damage or spinal cord damage.

We should give 781.99, 729.89 (weakness in limbs), hemiparesis, paralysis,
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 also
considered 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, ECG
interpretation, 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
________________

PE:-high risk, AKI, LMWH, all anticoagulants, Coumadin, heparin, deleparin, ESRD
Suicidal ideation, homicidal ideation, pregnancy, delirium, AIDS, etc are also
considered 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 and
weakness except generalized weakness as high risk for PMR. Also brain
damage or spinal cord damage.
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 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



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 EPIC
provider # R01317



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

1 chart is pending for this provider detsilsThis is a resident


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


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 SER
MED 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 BUTTOM
COLUMNS, billing area RTP for initial V42.0
SV+HD == CODE ONLY HD
DC+HD== CODE ONLY HD

IN SUBSIQ WE HAD TO SEE NOTE PT SEEN ON DIALYSIS, LINKAGE, THEN CODE ONLY HD IF NOT ( ANY
THING M,IS)CODE SV

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


4)CODE BILLING AREA FOR IFD AS IDP IF PATIENT HAS AIDES /HIV AND USE DIAGNOSIS AS v08 FOR HIV
AND 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 table
ANS:-YES



History elements ???\


ANS :-can take

HUDOCK,KRISTIN MD
ROGER,COHEN B MD
786.6,