Inpatient progress note: No complaints, Hx bleeding ulcer 2 yrs. ago
Labs: WBC-10.5 Hemoglobin-10.5 Hematocrit-30.6
Heart: RRR
Lungs: CTA
Abd: soft, NT, No HSM, BS normal, CVAT, no hemorrhoids
Small umbilical hernia, easily reducible stools + for occult blood
A/P: GI bleed, umbilical hernia
Additional “Queried” diagnosis: blood loss anemia based on lab values. If blood loss anemia 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
