Sandy Tyler was admitted to the hospital on July 4 for treatment of a fractured pelvis, which he sustained while parasailing earlier in the day. On July 5, his attending physician (an orthopedic surgeon) wrote a physician’s order requesting a neurologist to consult with the patient regarding numbness of his left foot.
Which diagnosis should the orthopedic surgeon report to justify inpatient E/M services? Which diagnosis should the neurologist report to justify inpatient E/M consultation services?
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Introduction: When a patient is admitted to a hospital, physicians from different specialties may be required to consult and manage the patient’s care. It is important for the attending physician to report the appropriate diagnosis to justify inpatient E/M services and consultations from other specialists.
Answer: The orthopedic surgeon should report the diagnosis of a fractured pelvis to justify inpatient E/M services. The neurologist should report the diagnosis of numbness in the left foot to justify inpatient E/M consultation services. Both diagnoses are relevant to the patient’s condition, and it is important for each physician to document the specific reason for their involvement in the patient’s care.
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