Wiki Coding help - I have the following note: pt here for PE with lab review

[snjberry]

I have the following note: pt here for PE with lab review. I think this should be 99396 w/ V70.0 as well as 272.4, 415.19 but MD coded 99214
Please help
HPI: a 43 yr old female with history of mildly elevated cholesterol who comes in once a yr to go over blood work she has no other complaints. she needed to be seen to get her numbers so she could send to her health ins. co. as they give her discount. this is done yearly.
Current Meds: none
Past Medical History: pulonary embolism thought to be related to birth control and long trips
Surg Hx: ankle ORIF, bladder suspension, unspec
family hx: father seizures, mother heart disease, diabetes
Social hx: works as manager
allergies: cipro / headaches
ROS: General review: negative for constitutional, HEENT, PULM, CARDIO, ENDO, GI, GU/GYN,MSK, DERM, NEURO, PSYCH except as noted in HPI.
vitals: temp, HR, BP, O2, wt, Ht, BMI all present
Lab review...all labs listed from 8/8/13 and reviewed
Exam
General appearance: is in no acute distress, pleasant, alert
HEENT: Head, normocephalic/atraumatic, tympanic membranes normal , clear conjuctiva, no conjuctiva erythema, no discharge, nonicteric, pupils equal, round, reactive to light, oropharnyx clear with mucous membranes, parhynx and tonsils normal.
NECK/THYROID: no lympadenopathy, supple no thyroid abnormality
CARDIO: regular rate and rythm, normal s1s2 no murmurs, click or rubs
RESPIRATORY: clear to auscultation bilaterally, no wheezes, rhonchi, rales
SKIN: no rash or skin lesions no ecchymosis, normal temp
EXTREMETIES: no clubbing no edema
MUSCULOSKELETAL: normal range of motion all joints
PSYCH: affect normal good eye contact, oriented to person, oriented to place, oriented to time, normal speach
ASSESSMENT: 1. HYPERLIPERDEMIA 2. PULONARY EMB. IN FARCT.

TX: REDO LIPID PANEL
STOP ALL BIRTH CONTROL FOR PULMONARY EMBOLISM
conducted pre visit prep: yes visit summary given to pt: Provided info about new and /or existing prescriptions, assessed patient understanding of medication, and pt response to med as well as any barriers to adherence. Yes. Education matieral given to pt. no counseling provided on nutrition/exercie. Written tx plan providing barriers assessed and addressed. Written self mgmt plan provided and developed with pt/family. self monitoring tool given to pt.
addendum completed pt is also here for well visit 99396 with v70.0.

RETURN 6MO

Thank you

 

[cdr4life]

you can code a 99214 with the appropriate age physical with a modifer 25 on each line item for instance

99395 25 v70.0
99214 25 (all other diagnoses without the v70.0)

hope this makes sense and helps you out

happy coding

 

[mitchellde]

I disagree, in order to charge a visit level and a preventive you must be able to separate out the elements of the office encounter from the elements of the preventive. You are unable to separate the elements in this note and still have an office visit of any significance. It states this is an annual without any additional complaints by the patient, which makes this only an annual preventive. You cannot charge an additional office visit without a symptomatic complaint from the patient. The affordable care act states that if the primary reason fpr the encounter is preventive then there cannot be a separately reported office visit. Icd-10 CM codes will prevent this with the wording of the preventive visit dx codes.