Coded: 401.9, 496, 607.84, 272.4, 250.00, 600.00, 437.9 and 99214 - still says I am missing another code - any help would be appreciated.
CHIEF COMPLAINT: Follow-up on several chronic conditions.
HISTORY OF PRESENT ILLNESS: Established patient is a very pleasant 64 year-old white male who presents for follow up for multiple chronic conditions. Unfortunately, he did not bring all his medications in. He is not very familiar with which medications he is taking. He does state he is taking 5 medications daily. He denies fevers, chills, headaches, loss of consciousness, dysuria, or diarrhea. His blood sugars are under good control. Lipids are under good control but blood pressure persists in being elevated. He has not been keeping a record of his blood pressure. He unfortunately, is continuing to smoke. He does not drink. He denies fevers, chills, headaches, loss of consciousness, dysuria, or diarrhea.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 168/90. Pulse 88. Respirations 18. Weight 234. Recheck on blood pressure is 150/88.
CHEST: Clear to auscultation.
CARDIOVASCULAR: Regular rate S1 and S2.
ABDOMEN: Soft, nontender. Nondistended. Positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis, or edema.
ASSESSMENT: 1. Hypertension, not to target goal questionable medical compliance. 2. Adult onset noninsulin-requiring diabetes, stable. 3. Mixed hyperlipidemia, stable. 4. BPH with urinary frequency, clinical improved with Flomax. 5. COPD, with continued tobacco abuse. 6. Cerebrovascular disease with history of CVA residual right-sided weakness and ongoing disability. 7. Erectile dysfunction.
PLAN: I have again counseled him on the importance of eating properly, exercising and weight reduction and avoidance of sodium. I have also asked him to keep a written down running list of blood pressures and have showed him how to do so. I have asked him also to bring in his medications at all appointments so we can review these. I have stressed the importance of discontinuance of smoking as well. I reviewed his lab data with him. I refilled his long-term medications. I have added Amlodipine 5 mg p.o. q day. Set up for a blood pressure recheck with the nurse practitioner in 3 weeks. If doing well at that time, we will set up for his lab appointment after May 15th and will get CBC, CP, lipid, UA, TSR, PSA, hemoglobin A1C, Microalbumin also EKG and chest x-ray but not set up an actual appointment. We will call him once we see the lab and get him worked in to be seen as he misses scheduled appointments.
CHIEF COMPLAINT: Follow-up on several chronic conditions.
HISTORY OF PRESENT ILLNESS: Established patient is a very pleasant 64 year-old white male who presents for follow up for multiple chronic conditions. Unfortunately, he did not bring all his medications in. He is not very familiar with which medications he is taking. He does state he is taking 5 medications daily. He denies fevers, chills, headaches, loss of consciousness, dysuria, or diarrhea. His blood sugars are under good control. Lipids are under good control but blood pressure persists in being elevated. He has not been keeping a record of his blood pressure. He unfortunately, is continuing to smoke. He does not drink. He denies fevers, chills, headaches, loss of consciousness, dysuria, or diarrhea.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 168/90. Pulse 88. Respirations 18. Weight 234. Recheck on blood pressure is 150/88.
CHEST: Clear to auscultation.
CARDIOVASCULAR: Regular rate S1 and S2.
ABDOMEN: Soft, nontender. Nondistended. Positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis, or edema.
ASSESSMENT: 1. Hypertension, not to target goal questionable medical compliance. 2. Adult onset noninsulin-requiring diabetes, stable. 3. Mixed hyperlipidemia, stable. 4. BPH with urinary frequency, clinical improved with Flomax. 5. COPD, with continued tobacco abuse. 6. Cerebrovascular disease with history of CVA residual right-sided weakness and ongoing disability. 7. Erectile dysfunction.
PLAN: I have again counseled him on the importance of eating properly, exercising and weight reduction and avoidance of sodium. I have also asked him to keep a written down running list of blood pressures and have showed him how to do so. I have asked him also to bring in his medications at all appointments so we can review these. I have stressed the importance of discontinuance of smoking as well. I reviewed his lab data with him. I refilled his long-term medications. I have added Amlodipine 5 mg p.o. q day. Set up for a blood pressure recheck with the nurse practitioner in 3 weeks. If doing well at that time, we will set up for his lab appointment after May 15th and will get CBC, CP, lipid, UA, TSR, PSA, hemoglobin A1C, Microalbumin also EKG and chest x-ray but not set up an actual appointment. We will call him once we see the lab and get him worked in to be seen as he misses scheduled appointments.