Our Drs. have been doing consults for Sx Colonscopy in the clinic setting thinking they would get RVU’s on top of the surgery itself. We have been holding them due to MDCR stating this is a nonbillable service with the only reason is for screening since the procedure it self has the RVU’s for the PreOp/IntraOp/Postop. Finally Admin has meet with the providers regarding this. Our providers feel they should be given an RVU still for there time. They understand this visit can not be billed out. So Administration has asked us to work up the visit levels to see what RVU’s would need to be given to our providers. Please visit below this is what 90% of these visits look like. I’m only able to work this up to a 99212. Yes, the Risk is moderate but the number of dx and data is minimal which leaves me with an overall Straightforward 99212. Provider feels he should get credit for a 99214 since the Risk is moderate by itself. Any advice and help would be great. Again we are not billing these out…this is for internal training purposes.

Primary Provider:

CC: Colonoscopy Consult

History of Present Illness:
is referred for screening colonoscopy. Last scope 2013 and was nl. Has hx of colon polyps. No change in bowels or blood in stool. No issues with anesthesia.

Family Hx + for colon CA

Past Medical History:

Reviewed history from 08/27/XXXX and no changes required:

hyperlipidemia

thyroid disease

colon polyps- scope due 20XX

Past Surgical History:

Reviewed history from 08/27/20XX and no changes required:

Colonoscopy 20XX

Family History Summary:

Reviewed history Last on 01/03/20XX and no changes required:03/05/20XX

General Comments – FH:

father- died squamous cell CA metastatic to neck (?primary?)- 84; colon cancer, skin cancer, CVA, hypertension, hyperlipidemia

mother- skin cancer, CAD, type II diabetes, macular degeneration

1/2B- CAD

S- high cholesterol

Previous Tobacco Use: Signed On – 01/03/20XX

Smoked Tobacco Use: Former smoker
Cigarettes: Yes
Pack-years: 5
Year started: 1978
Year quit: 1988
Years Since Last Quit: 31 years, 2 months, 4 days
Smokeless Tobacco Use: Never
Passive smoke exposure: no
Drug use: none
HIV high-risk behavior: no
Caffeine use: Drinks coffee 1-2 times per day. drinks per day

Previous Alcohol Use: Signed On – 01/03/20XX

Alcohol use: yes
Type: 5 times per week, 2 glasses wine
Drinks per day: <1
Exercise: yes
Times per week: 5
Type of Exercise: hiking, snow shoe
Seatbelt use: 100 %

Family History Risk Factors:
Family History of MI in females < 65 years old: no
Family History of MI in males < 55 years old: no

Review of Systems

General

Denies fatigue, malaise and weight loss.

ENT

Denies difficulty swallowing.

CV

Denies chest pain or discomfort and racing/skipping heart beats.

Resp

Denies shortness of breath.

GI

Denies change in bowel habits and bloody stools.

Heme

Denies bleeding and abnormal bruising.

Allergy

no anesth rxn

Vital Signs:

Patient Profile: Years Old

Height: inches (170.18 cm)

Weight: pounds

BMI: .18

BSA: 1.78

Temp: 96.8 degrees F temporal

Pulse rate: 70 / minute

Pulse rhythm: regular

BP Sitting: 140 / 70 (left arm)

Cuff size: large

Problems: Active problems were reviewed with the patient during this visit.

Medications: Medications were reviewed with the patient during this visit.

Allergies: Allergies were reviewed with the patient during this visit.

Vitals Entered By:

Physical Exam

General:

well developed, well nourished, in no acute distress.

Mouth:

no deformity or lesions with good dentition.

Neck:

no masses, thyromegaly, or abnormal cervical nodes.

Lungs:

clear bilaterally to auscultation.

Heart:

regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops

Blood Pressure:

Today’s BP: 140/70 mm Hg

Labwork:

Most Recent Lab Results:

LDL: 195.8 mg/dL 08/31/20XX

Test Management:

Tests Reviewed:

BUN: 15 Results from two years ago

Creatinine: 0.75

Sodium: 139

Potassium: 4.6

Chloride: 104

HGB: 12.8

HCT: 39.9

MCV: 91.1

MCH: 29.2

MCHC:

32.1 G/DL ()

Platelets: 290

Impression & Recommendations:

Problem # 1: Encounter for screening for malignant neoplasm of colon (ICD-V76.51) (ICD10-Z12.11)

Proceed with colonoscopy. The risks, benefits, and possible complications including the possibility of perforation, bleeding, missed lesion & anesthesia reactions were explained. Pt understood and agreed to proceed, signing the consent form. We will schedule this shortly.

Patient is ASA class II, MAC not indicated

Copy of this note routed to PCP

Medications Added to Medication List This Visit:

1) Trilyte 420 Gm Oral Solution Reconstituted (Peg 3350-kcl-na bicarb-nacl) …. Take this prep after 2 hours or first bowel movement from biscodyl tablets

2) Dulcolax 5 Mg Oral Tablet Delayed Release (Bisacodyl) …. 2 tabs orally, then take at least 1/2 of the peg-3350 solution.

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