# E7M, Preventative or both



## gwenav (May 7, 2012)

*E&M, Preventative or both*

I was wondering if someone could help me with this. Some feel both E&M and Preventative should be attached, others in the office say just E&M. Who is right 



Subjective:

 CC: 
    1. 18 yo female presents for annual gyn and Depo. Currently sexually active x 1 male x 1 week. Current Partner Denies: STDs, IVDU, Other Partner, Bisexual. Using condoms, though h/o unprotected sex 6 days ago. h/o irreg menses, never skips more then 2 mos, at times 2 x mos, but rare. . 2. Denies current meds.  

 HPI: 
   New symptom(s):  
       No complaints, unless otherwise noted.
   Alcohol/Tobacco/Drug Use:  
       Smoking status Never smoked. Alcohol use none. Drug use none. 
   GYN History:  
       Menses:  
4/19/12, irregular menses

. Last Pap: never. Abnormal pap smear: none. Menarche: 10 years. Menopause: N/A. Last mammogram: N/A. Breast complaints: none. Breast self-exam: discussed BSE. Gravida 0. Para 0. 
   Education/Counseling:  
       Education/counseling provided: Reproductive/life planning, Contraception, Infertility, Desires pregnancy, Pregnancy, Sterilization, HIV risk, Immunization, Hypertension, Nutri/Folate, STD, Smoking, PAP, Sexual coercion, ECP, BSE, Options counseling. Parental involvement discussed (if teen): N/A.  

 Medical History: Irregular Heart Beat - w/u as child, told will not interfere with lifestyle..  

 Gyn History:  Periods :  Irregular, never skips >2 mos, rarely 2x mos..  Sexual activity  currently sexually active, with men.  Last pap smear date  Never.  Sexually Transmitted Diseases (STDs)  none.  Birth control  condoms.  Menarche:  age of onset   10.  

 OB History:  Total pregnancies  0.  Total living children  0.   

 Surgical History: T&A .  

 Family History:   

 Social History:   

 Medications: None 

 Allergies: N.K.D.A. 


Objective:

 Vitals: Pain scale 0 1-10, BP 122/88 mm Hg, Ht 63 in, Wt 173 lbs, BMI 30.64 Index, Wt % 93.69 %, BMI % 95.05 %, Ht % 31.25 %. 

   Past Orders: 

 Examination: 
   General Examination: 
       NECK/THYROID: no thyromegaly, no masses.  HEART: no murmurs, regular rate and rhythm.  LUNGS: clear to auscultation bilaterally, no wheezes, rales, rhonchi.  ABDOMEN: no guarding, no rebound, non-tender, no masses.  EXTREMITIES: no varicosities, no edema.      
   Gynecological: 
       BREASTS: normal, no lymph adenopathy, no lumps palpated bilaterally, no nipple discharge, no skin changes, non-tender.  EXTERNAL GENITALIA: introitus normal, no erythema, no lesions.  VAGINA: clear discharge, healthy pink mucosa without any lesions, normal.  CERVIX: no discharge, no cervical movement tenderness, no lesions.  UTERUS: normal size, shape and consistency, non-tender to exam, no obvious masses.  ADNEXA: adnexa normal with no masses and nontender to exam bilateraly.  RECTUM: not examined.      
   Family Planning - GRANT REQUIRED: 
       AFPC data (click here on green text to complete):  Present BCM:  Male Condom, Primary prescribed BCM:  3-Month Hormonal Injection (Depo-Provera), Secondary prescribed BCM:  No Method (e.g., partner sterile), BC contraindications?  no, CBE performed:  yes, Breast referral provided:  N/A, ABC Counseling provided:  Yes, First HIV test?  Yes, Other supplies provided:  condoms.      



Assessment:

 Assessment: 
1. General counseling for initiation of other contraceptive measures - V25.02  
2. Routine gynecological examination - V72.31   

Plan:

 1. General counseling for initiation of other contraceptive measures  
Annual GYN Exam: 1) Pap, gc/chl, RPR, HIV. 2) BSE taught. 3) Routine healthcare reviewed. 4) RTC 1 year.
Depo Rx and Counseling: 1) Consent signed. 2) Risks/ Benefits reviewed. SE reviewed. 3) Calcium encouraged. 4) Injection given. Condoms x 1 week. 5) h/o unprotected sex 6 days ago, pregnancy and Depo reviewed, advised if no bleeding to to urine preg in 3.5 weeks. 6) RTC 3 mos.    

2. Routine gynecological examination  
     LAB: Pregnancy Test, Urine            negative 

     LAB: Urine chem strip            ph 5.0, sp gr 1020, prt trc 

     LAB: RPR
     LAB: Chlamydia/GC Amplification
     LAB: HIV FingerStick Lab            negative 

     LAB: Hemoglobin            13.7 


3. Others   
Post-Education/Counseling provided on breast and cervical cancer screening, reproductive health, STD/HIV risk factors, symptoms and treatment. Exam & follow-up instructions reviewed as necessary. Emergency information given. Patient states understanding.


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## Skenyon (May 31, 2012)

*Look like an Annual Gyn Exam to Me*

Looks like an annual gyn exam.  I would only code this using a preventive exam code.
Basically all of this visit was just as the preventive medicine codes state: _age and gender appropriate history, examination, counceling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures._


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## rthames052006 (May 31, 2012)

As Skenyon stated this is strictly a preventive visit only, I"m unclear as to where someone picked out an e/m as well as the preventive piece.


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