# ov level?



## SHobbs (Aug 30, 2013)

I need another opinion on this... Can you get a detailed history, comprehensive exam, and moderate mdm?  I appreciate any advise and expertise on this.



Vital Signs:
Time: 		03:04 PM
Weight: 		170 lbs
Height: 		65"
BMI: 		28.29
BSA: 		1.88
Temperature: 	98.0 F (Oral)
BP: 		158/68(Right Arm)(Sitting)
Pulse: 		113(Apical)(Standing)(Regular)
Respiration: 	20
Oxygen: 		98(Room air)

Chief Complaint:

Patient states she is here for a chief complaint of hands cramping and going to sleep .
labs.

Current Medication:
1 Albuterol 0.83 Mg/ml Solution 2.5 Mg /3 Ml (0.083 %)  nebulizer every 4 to 6 hrs prn 
2 Singulair 10 Mg Tablet  Take 1 daily 
3 Symbicort 160-4.5 Mcg Inhaler Mcg/actuation  Inhale 1 puff twice a day 
4 Iron 325 Mg Tablet (65 Mg Iron)  Take 1 twice daily 
5 Zantac 150 Mg Tablet  Take 1 twice daily 
6 Campral Dr 333 Mg Tablet  Take 1 three times a day 
7 Buspirone Hcl 15 Mg Tablet  Take 1 twice daily increase  
8 Tramadol Hcl 50 Mg Tablet  Take 1 by mouth three times a day 
9 Levothyroxine 125 Mcg Tablet  Take 1 daily 
10 Proventil Hfa 90 Mcg Inhaler Mcg/actuation (Other MD)  
11 Nexium 40 Mg Capsule (Other MD)  Take 1 by mouth twice a day 
12 Requip 1 Mg Tablet (Other MD)  Take 1 by mouth twice a day 
13 Celexa 10 Mg Tablet (Other MD)  Take 1 by mouth daily Dr Parvez 
14 Transderm-scop 1.5 Mg/72hr (Other MD)  Apply 1 patch every 72 hours 
15 Trazodone 50 Mg Tablet (Other MD)  Take 11/2 by mouth at bedtime 

Allergy/Adverse Reaction:
Penicillins, Cyclobenzaprine

Social History:
Social history was reviewed & updated on Aug 29, 2013 by xxx , MA.
xxx currently smokes 2 packs per day  .
Patient does drink alcohol. She reports drinking occasionally for 30 years.
She denies recreational drug use.
Patient is married.
Patient has no recent travel. She reports exposure to 2nd hand smoke.

Family History:
Family history reviewed and unchanged on Aug 29, 2013 by xxx, MA. Patient is adopted and does not know her genetic family history.

Medical History:
Reviewed and unchanged on Aug 29, 2013: allergies, current medication list (including problems or difficulties taking the medications were documented as needed), medical history, immunizations, by xxxx, MA.
She has not been hospitalized or visited the ER in the last 12 months.
xxx has not seen a specialist since last visit.
Specialist(s) seen: Gastroenterology: xxxx

Collaborative Tracking: .
Preventative Screenings: Has had an preventative eye exam on Jan 16, 2013. Patient has not had a preventative dental exam in the last year. dentures.

Asthma.
Chronic obstructive pulmonary disease.
Emphysema.

Hyperlipidemia.

Gastroesophageal reflux.

Depression.
Hepatitis C. Diagnosed at the age of 18.

Surgeries- Procedures:
Appendectomy  1974,.
Caesarean section  1974,1977,.
Carpal tunnel release Left,.
Hysterectomy in 2002 (vaginal , complete)., esophageal 10 /2010
RT shoulder absess 1964
.

50% clots in legs.

Ob/Gyn History:
OBGYN history reviewed and unchanged on Aug 29, 2013 by xxx, MA.
Date of LMP: 2002.
Gravida 2 para 2  .
No history of STI exposure or disease.

She had a mammogram on 2010 which showed normal result States she is probably due for another one.
Performs self breast exam. Monthly.
Patient went through menopause at age: 2002 mammogram 2010. Patient states last pap about 2 years ago and was normal.

HPI:
PHQ reviewed. No follow-up or treatment needed at this time. Musculoskeletal:
Patient is here for joint pain.It is located at both hands. It was noted 5 months ago. It happened insidiously. It lasted for 5 months. Occurs intermittently. The condition has been fluctuating  ever since. She describes pain as aching, constricting, cramping and spasmodic. She could not recall any precipitating event that could have lead to the condition. Patient denies strain, cramps, tingling, weakness, and myalgias. No aggravating factors noted. The patient complains that the pain is constant. There is no pallative factors. It does not seem to decrease with rest or other measures. Patient has had no similar problem in the past. She has not tried any form of treatment for the condition. Despite her illness, she is able to perform activities of daily living and is able to work. She is not frustrated, anxious or depressed about it.

ROS:
See HPI.

Current medications reviewed. Xxx claims she is compliant with medications and has experienced no side effects. Past medical history, family history, and social history reviewed.

Examination:
General: The patient is alert and active. She appears well groomed and in no acute distress. Vital signs noted.
Lymphatic: No lymph node enlargement or tenderness noted. There is no evidence of acute or chronic lymphedema.
ENT: Bilateral ear canals clear, TM's appropriate in color with good cone of light. Nasal mucosa pink, no sinus tenderness. Oral mucosa pink, moist, without lesions. Posterior pharynx pink, moist, without exudate.
Respiratory: Lungs are clear to auscultation. No wheezes, rales, or rhonchi noted. Respirations are equal and unlabored.
Cardiovascular: Heart rate is regular. S1 and S2 present with no audible murmurs noted. PMI is non displaced. Peripheral pulses intact, 2+ bil. No pedal edema noted.
Musculoskeletal: There is no evidence of joint pain, tenderness or deformity. Full Range of motion intact to all major joints.
Neurologic: Alert and oriented X 3. Cranial nerves II-XII are grossly intact.
Psychiatric: Appropriately dressed. Does not appear anxious or withdrawn. Speech and affect are appropriate.

MMSE/PHQ/SBIRT:
PHQ:
PHQ2 - 13 & Older-If Yes to Either, Go to PHQ9: 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:
782.0      Skin Sensation Disturbance 070.51      Hepatitis C 244.9      Hypothyroidism Not Otherwise Specified 285.9      Anemia nos 305.1      Tobacco Use Disorder V65.42      Counseling on Tobacco and/or Substance Abuse 

Prescription:
Changed/Discontinued Medication(s): 
   Discontinued: CAMPRAL DR 333 MG TABLET

Care Plan:
Patient Education:

Readiness for Change: xxx was assessed for her readiness to make changes in lifestyle for disease prevention and/or long-term disease management.
Does patient eat at least 2-1/2 cups of fruits and vegetables each day? Patient is not interested in eating fruits and vegetables and has no plans to change at this time (Pre-Contemplation).
Has patient quit smoking/never smoked? Patient is not interested in quitting smoking and has no plans to change at this time (Pre-Contemplation Stage).
Is patient physically active for 30 or more minutes for 5-7 days a week? Patient is physically active and has been for six (6) months or longer (maintenance stage).

Tobacco Cessation: Tobacco cessation counseling provided. Benefits of Quitting and Rewards For Kicking the Habit given..

Status: stable.
Medications: Continue all current medications Current medications reviewed with patient including side effects, benefits and risks. Proper method of taking discussed. Patient-Family understands instructions for the medication(s).
FOLLOW-UP: Return sooner if the condition changes, worsens, or does not resolve. If condition worsens, call xxxxx to schedule an appointment with your primary care provider, or after hours, call on-call provider at xxx. All questions were addressed. Patient/caretaker appears to clearly understand and is comfortable with careplan. Discussed treatment plan and expected course..
INSTRUCTIONS: to wear wrist brace for 2 weeks to relieve pressure on wrist nerves.

Educational Handouts:
(1) Benefits of Quitting (PreContemplation)
*


This visit note has been electronically signed off by following providers.
This visit note has been electronically signed off by xxx on xxx at 08:40 PM.


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## FTessaBartels (Sep 11, 2013)

*A lot of noise ...*

This is one of the worst examples of over-documentation I have ever seen .. and I question whether much of it is just cloned.

You have a comprehensive history
You have a comprehensive exam (per 1995 guidelines)
You have STRAIGHTFORWARD MDM  


If it's an *existing patient* you have a level 2 visit 99212 because of the MDM

If this is a *new patient* then you have a level 2 visit 99202 because of the MDM.  So why have the over-documentation of history and PE?  And by the way ... your chief complaint is joint pain in both hands and the first statement under Musculoskeletal in the PE is: *There is no evidence of joint pain, tenderness or deformity. Full Range of motion intact to all major joints.*  (emphasis added by FTB)

See why I think this is cloned?

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## OCD_coder (Sep 11, 2013)

I have to agree with Tessa that the nature of the presenting problem does not support the over-documentation that was recorded by the provider.  

But, I did not find 10 organ systems (ROS) documented to support a Comprehensive Hx unfortunately.  It wasn't needed though with the presenting problem.   I can get a detailed Hx out of it, but I can't support a moderate MDM with wrist pain and a brace given for treatment.  This is a low MDM at best if this is a new problem, it's just unclear to the reader if the patient is new or established that should be documented in the Chief Complaint.

 Also, why is the provider doing tobacco cessation when that isn't the reason the patient was seen for.


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## MikeEnos (Sep 13, 2013)

I agree, there is superfluous and conflicting information here that calls the integrity of this note into question.

Here's something else that confused me:



> Prescription:
> Changed/Discontinued Medication(s):
> Discontinued: CAMPRAL DR 333 MG TABLET



Ok, so Campral (which is listed near the top as one of the current medications) was discontinued.  But a little later in the note.....



> Status: stable.
> Medications: Continue all current medications Current medications reviewed with patient including side effects, benefits and risks. Proper method of taking discussed. Patient-Family understands instructions for the medication(s).



*ಠ_ಠ*


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