Arubaismyhappyplace
Guest
- Messages
- 30
- Best answers
- 0
I need some help on this subject.
Patient presented for PAP and the provider also did a breast exam.
Our biller and provider want to bill for 99212 on the grounds that the patient has not had a breast exam in 4 years. I feel we should only be billing for the PAP and breast exam.
She is not complaining of any lumps, drainage or pain. she is requesting referral for mammogram.
I have included the note below for review. Thank you for any advice you may have to give.
Chief Complaint
The Chief Complaint is: Pap Smear & mammo script.
History of Present Illness
• Medication list reviewed.
° No breast lump ° No nipple discharge ° No pain in breast
63-year-old female that presents today for her annual Pap smear. She reports that they have been several years since her last Pap. She reports that she went into menopause in her 50s. After some discussion and chart review we have figured out that it was around 10/31/2008. She reports that she has been feeling well. She reports that she at one time did have an abnormal Pap. She is also requesting a prescription for a mammogram.
She denies any incontinence.
Review Of Systems
Systemic: Not feeling tired (fatigue). No fever and no chills.
Breasts: No breast lump, no nipple discharge, no inversion of the nipple, and no pain in breast.
Cardiovascular: No chest pain or discomfort.
Pulmonary: No dyspnea and no cough.
Gastrointestinal: Normal appetite and no abdominal pain.
Genitourinary: No increase in urinary frequency. No urinary urgency. No urinary loss of control and no dysuria. No genital lesion. Menopause occurred at age 53. No menopausal concerns. No vaginal discharge.
Endocrine: No polydipsia and no excessive sweating.
General Appearance:
° Normal. ° Well developed. ° Well nourished. ° In no acute distress.
Lymph Nodes:
° Supraclavicular lymph nodes were not enlarged.
Breasts:
General/bilateral:
• Soft breasts. ° Appearance of the breast was normal. ° Palpation of the breast revealed no abnormalities. ° No breast mass was found. ° No tenderness of the breast.
Lungs:
° Normal breath sounds/voice sounds. ° No wheezing was heard. ° No rhonchi were heard.
Cardiovascular:
Heart Rate And Rhythm: ° Normal.
Heart Sounds: ° S1 normal.
Abdomen:
Auscultation: ° Bowel sounds were normal.
Palpation: ° Abdominal non-tender.
Pelvic:
Vagina: ° Normal.
Cervix: • Pap smear sample taken. ° Normal. ° No cervical discharge.
Uterus: ° Position was normal. ° Not tender.
Uterine Adnexae: ° Uterine adnexa was not tender on the right. ° Uterine adnexa was not tender on the left.
Neurological:
° Oriented to time, place, and person.
Skin:
° General appearance was normal.
Assessment
• Visit for: gynecological exam with pap smear
Plan
gynecological exam with Pap smear. Patient tolerated procedure well without complaints. I have given her prescription for mammogram. As she has not had one since 2014. We have discussed supportive measures.
Follow-up as priorly scheduled or sooner if needed.
Patient presented for PAP and the provider also did a breast exam.
Our biller and provider want to bill for 99212 on the grounds that the patient has not had a breast exam in 4 years. I feel we should only be billing for the PAP and breast exam.
She is not complaining of any lumps, drainage or pain. she is requesting referral for mammogram.
I have included the note below for review. Thank you for any advice you may have to give.
Chief Complaint
The Chief Complaint is: Pap Smear & mammo script.
History of Present Illness
• Medication list reviewed.
° No breast lump ° No nipple discharge ° No pain in breast
63-year-old female that presents today for her annual Pap smear. She reports that they have been several years since her last Pap. She reports that she went into menopause in her 50s. After some discussion and chart review we have figured out that it was around 10/31/2008. She reports that she has been feeling well. She reports that she at one time did have an abnormal Pap. She is also requesting a prescription for a mammogram.
She denies any incontinence.
Review Of Systems
Systemic: Not feeling tired (fatigue). No fever and no chills.
Breasts: No breast lump, no nipple discharge, no inversion of the nipple, and no pain in breast.
Cardiovascular: No chest pain or discomfort.
Pulmonary: No dyspnea and no cough.
Gastrointestinal: Normal appetite and no abdominal pain.
Genitourinary: No increase in urinary frequency. No urinary urgency. No urinary loss of control and no dysuria. No genital lesion. Menopause occurred at age 53. No menopausal concerns. No vaginal discharge.
Endocrine: No polydipsia and no excessive sweating.
General Appearance:
° Normal. ° Well developed. ° Well nourished. ° In no acute distress.
Lymph Nodes:
° Supraclavicular lymph nodes were not enlarged.
Breasts:
General/bilateral:
• Soft breasts. ° Appearance of the breast was normal. ° Palpation of the breast revealed no abnormalities. ° No breast mass was found. ° No tenderness of the breast.
Lungs:
° Normal breath sounds/voice sounds. ° No wheezing was heard. ° No rhonchi were heard.
Cardiovascular:
Heart Rate And Rhythm: ° Normal.
Heart Sounds: ° S1 normal.
Abdomen:
Auscultation: ° Bowel sounds were normal.
Palpation: ° Abdominal non-tender.
Pelvic:
Vagina: ° Normal.
Cervix: • Pap smear sample taken. ° Normal. ° No cervical discharge.
Uterus: ° Position was normal. ° Not tender.
Uterine Adnexae: ° Uterine adnexa was not tender on the right. ° Uterine adnexa was not tender on the left.
Neurological:
° Oriented to time, place, and person.
Skin:
° General appearance was normal.
Assessment
• Visit for: gynecological exam with pap smear
Plan
gynecological exam with Pap smear. Patient tolerated procedure well without complaints. I have given her prescription for mammogram. As she has not had one since 2014. We have discussed supportive measures.
Follow-up as priorly scheduled or sooner if needed.
Last edited:
