debipbarik
Networker
Can anybody code this with reason for codes? This visit needs to be coded for Newyork state Medicare. Pt is established..
"Subjective:
Pt seen for follow up with Bipolar disorder, depressed with psychotic disorder, dementia and
depression. She had an agitated episode and struck out at another resident who grabbed her.
Objective:
Pt noted to be tryingto elope from the facility. She is still on waiting list for assisted
living. Meds include depakote 500, Zyprexia 20mg daily and paxil 20mg daily.
Assessment:
Pt is more irritable, Angry and aggressive recently and is frustrated about being sent to
assisted living so far. Mood is more dysphoric.
Depakote level is 35.8 which is sub therapeutic.
Plan:
1- Increased depakote to 250mg AM and
2- To repeat depakote level in 1week
3- To get T4 and TSH
4- Follow up in 2 weeks"
"Subjective:
Pt seen for follow up with Bipolar disorder, depressed with psychotic disorder, dementia and
depression. She had an agitated episode and struck out at another resident who grabbed her.
Objective:
Pt noted to be tryingto elope from the facility. She is still on waiting list for assisted
living. Meds include depakote 500, Zyprexia 20mg daily and paxil 20mg daily.
Assessment:
Pt is more irritable, Angry and aggressive recently and is frustrated about being sent to
assisted living so far. Mood is more dysphoric.
Depakote level is 35.8 which is sub therapeutic.
Plan:
1- Increased depakote to 250mg AM and
2- To repeat depakote level in 1week
3- To get T4 and TSH
4- Follow up in 2 weeks"