# Billable?



## SHobbs (May 17, 2012)

Is this something that we can even bill for?  The patient doesn't have a chief complaint?


Vital Signs:
Time: 		04:26 PM
Weight: 		212 lbs
Height: 		62"
BMI: 		38.77
Temperature: 	98.0 F (Oral)
Waist Circumference: 	46 inches
BP: 		118/60(Left Arm)(Sitting)
Pulse: 		100
Oxygen: 		97

Chief Complaint:

Pt here to have a letter stating that she has Asthma and Thyroid problems.

Current Medication:
1 Albuterol Sulf Hfa 90 Mcg Inh Mcg/actuation (Other MD)  SIG: Inhale 2 puff every 4-6 hours as needed

Allergy/Adverse Reaction:
No Known Allergies

Social History:
Social history was reviewed & updated on May 14, 2012 by MA.
 currently smokes one pack per day  .  started smoking at the age of 12.
She denies alcohol use.
She denies recreational drug use.
Patient is married.
The patient does not do any form of exercise.
Caffeine intake consists of soda. She drinks 2 cans of soda per day.
Patient has no recent travel.

Family History:
Family history reviewed and unchanged on Dec 22, 2011 by , LPN. Patient's father is deceased. He died at the age of 54 due to complications of diabetes. He suffered from congestive heart failure and diabetes type 1. Patient's mother is living. She is 45 years old., She has hyperthyroidism and lung cancer.
Patient has 5 brothers. All are in good health.
Patient has 1 sisters. Her first sister is older than her. She is 27 years old, has hypothyroidism and heart disease.
Patient has 1 sons.
Patient has 1 daughters. Patient's maternal grandmother has hyperthyroidism.

Medical History:
Reviewed & updated on May 14, 2012: allergies, current medication list, medical history, by MA.
Past medical history is unremarkable.
She has not been hospitalized or visited the ER in the last 12 months. Specialist(s) seen: Opthamology-Optometry: Dr. xxxx.
Surgical History: Surgical History:
Caesarean section Sept. 2009,.
Gallbladder surgery 1/2011.

Ob/Gyn History:
OBGYN history was reviewed & updated on Dec 22, 2011 by, LPN. Menarche at age 12. Menstrual cycle is irregular, lasting 4 days, with  flow light. Date of LMP:Feb 14, 2012 Gravida 3 para 2  . Connie is pregnant. Estimated due date is on Dec 2, 2012.  She is not breastfeeding.
Hx of Gyn DX: No history of significant gynecologic illnesses.
No history of STD exposure or disease.

Patient has had no previous mammogram exam. Does not perform self breast exam. Patient is sexually active. Per pt hisotry, last PAP done 8/2010 which resulted negative.

HPI:
20 year 11 month age old patient is here for request of a form
Per patient -she is dealing with immigration court for her spouse 
She was told by their lawyer that she needs a "letter" stating she has medical conditions of thyroid problems and asthma
Patient has not followed up on any issues with the thyroid 
.

PHQ reviewed.No follow-up or treatment needed at this time.

ROS:
See HPI.

Current medications reviewed and updated. Past medical history, family history, and social history reviewed and updated. She has not follow up on any thyroid issues.

Examination:
General: The patient is alert and active. She appears well groomed and in no acute distress. Vital signs noted.
Skin: Gross inspection of skin reveals no rash or lesions. Skin is warm and dry.
Respiratory: No respiratory distress.
Musculoskeletal:
GAIT: Normal gait.
Psychiatric: Appropriately dressed. Does not appear anxious or withdrawn. Speech and affect are appropriate.

MMSE/PHQ:
PHQ: PHQ2: Over the last 2 weeks, how often have you been bothered by any of the following problems? Feeling Down, Depressed, or Hopeless? No Little Interest or Pleasure in Doing Things? No.

Diagnosis:
v68.9      Administrtve encount nos V22.2      Pregnant State, Incidental 

Prescription:
Changed/Discontinued Medication(s): 
   Discontinued By Other MD: CHANTIX STARTING MONTH PAK 0.5 (11)-1 (42) MG

Plan:
Patient Education/Counseling: Medications reviewed with patient including possible side effects, potential benefits and associated risks. Proper method of taking medications discussed. Status:stable.
MEDICATIONS: Current medications reviewed with patient including side effects, benefits and risks. Proper method of taking discussed.
FOLLOW-UP: Return to clinic as needed. Return sooner if the condition changes, worsens, or does not resolve..
INSTRUCTIONS: Go to ER if worsening. Drink plenty of fluids. OTHER: *** Patient had extensive discussion with patient over what the "letter" she needed was in regards to - how to fill it out. and she did not have the "letter" when this was discussed more she notes that there is no letter and she might just need her medical records. 
Due to not following up she did not have diagnosis.


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## jmcpolin (May 17, 2012)

Man that is quite a report maybe your doctor could do an addendum and report more regarding the thyroid problem and asthma, and he does not even mention the pregnancy that he added a dx for.  He sure did a lot of work but left off some very key information.


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## ollielooya (May 18, 2012)

No kidding, Jennifer that is quite a report.  But I do see a CC even if it is as simple as what is stated.  We know both 95 and 97 guidelines state that the  CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or _other factor _that is the reason for the encounter, _usually_ stated in the patient's words.  

So as weak as it may appear it does seem to me that the CC has been meant.  What do you and others think?


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## dclark7 (May 18, 2012)

What I don't see here is medical necessity.  Patient needs a report for a third party (immigration court) and has not presented for medical treatment of her problems.  She actually does not seem to have any complaints at the time of this visit (per patient).  Most insurance companies won't pay for visits or for forms required by a third party.  I don't think this is a billable encounter.

Any other opinions?


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## FTessaBartels (May 18, 2012)

*Preventive Visit*

At first I was thinking this might be a preventive visit with completion of the form.  Of course, this will depend on whether the physician has already seen the patient for a preventive visit this year.  *However *...

I get the distinct impression that this is an EHR with most of the info being copy/pasted or templated from the record.  

I don't see the asthma addressed at all, other than mention of the albuterol. The only mention of thyroid is that she hasn't followed-up. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## DeeCPC (May 21, 2012)

I don't have my books with me but there is a code for filling out paperwork.  It might be 99080. 
Since it seems that there is no real medical necessity for this visit and the Doc documents the reason for the visit is for the form, I would not code and E/M.  

Dee
CPC, CPMA, CPCD


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