dorinda05
Networker
Looking for any help on this. I code for a family practice physician that basically codes each visit for her patient's that she has previously seen with the same prior diagnoses even though they don't particularly apply to the current visit (basically "cloning" previous visit codes) with the addition of the current visit diagnosis(es). For example, here is the most recent HPI:
Pt presents today with right shoulder pain/injury. Started 2 weeks ago when she was lifting heavy boxes of can goods and it is getting worse and keeping her up at night. Patient notes that she initially thought that she strained her right arm lifting heavy cases of food in her volunteer job at ******* House but now notes that she can't even pick up a phone in her right arm and she is right hand dominant. She notes that she has had grip strength weakness and cannot lift anything and is dropping things. She also notes that her writing is affected also. She volunteers 1 day a week and has 3, 2 and 5 year old at home. The 2 year old is still in a crib and she has to lift her out of the crib and is having to use her left arm She has not had any numbness or tingling in the right arm. She notes that the pain is a 7/10 most of the time and she notes that it is really bad at night and she cannot sleep at night.
Lov 6/2/15 for lab follow up and was placed on Benicar which she is still taking and labs were ordered for 3 months (due in sept).
Assessment/Plan
Assessment/Plan:
1. Degenerative spondylolisthesis
2. Varicose veins of both legs with edema
3. Right shoulder pain
4. DDD (degenerative disc disease), lumbar
5. Lupus (systemic lupus erythematosus)
6. Hypertension
7. Depression, major, in remission
8. Post menopausal syndrome
9. Post-menopausal osteoporosis
10. Neuropathy
11. Obstructive sleep apnea
New Medications
HYDROCODONE BIT/ACETAMINOPHEN (HYDROCODON-ACETAMINOPHN 10-325) 1 EACH TABLET:
1 EACH PO BID PRN #15
Instructions: the patient has a painful medical condition requiring treatment and this prescription is prior to her seeing pain management.
CYCLOBENZAPRINE HCL 10 MG TABLET: 10 MG PO QHS PRN #30
New Diagnostics
MR UPPER EXT JOINT W/O CON, First Available
Dx: Right shoulder pain
EVALUATION-PT, First Available
Dx: Right shoulder pain
New Referrals
Pain Management Referral
Advise
Dx: Right shoulder pain
All the above codes were used in this visit pertaining to her shoulder injury.
Can anyone point me in the right direction to see the guidelines on this?
Pt presents today with right shoulder pain/injury. Started 2 weeks ago when she was lifting heavy boxes of can goods and it is getting worse and keeping her up at night. Patient notes that she initially thought that she strained her right arm lifting heavy cases of food in her volunteer job at ******* House but now notes that she can't even pick up a phone in her right arm and she is right hand dominant. She notes that she has had grip strength weakness and cannot lift anything and is dropping things. She also notes that her writing is affected also. She volunteers 1 day a week and has 3, 2 and 5 year old at home. The 2 year old is still in a crib and she has to lift her out of the crib and is having to use her left arm She has not had any numbness or tingling in the right arm. She notes that the pain is a 7/10 most of the time and she notes that it is really bad at night and she cannot sleep at night.
Lov 6/2/15 for lab follow up and was placed on Benicar which she is still taking and labs were ordered for 3 months (due in sept).
Assessment/Plan
Assessment/Plan:
1. Degenerative spondylolisthesis
2. Varicose veins of both legs with edema
3. Right shoulder pain
4. DDD (degenerative disc disease), lumbar
5. Lupus (systemic lupus erythematosus)
6. Hypertension
7. Depression, major, in remission
8. Post menopausal syndrome
9. Post-menopausal osteoporosis
10. Neuropathy
11. Obstructive sleep apnea
New Medications
HYDROCODONE BIT/ACETAMINOPHEN (HYDROCODON-ACETAMINOPHN 10-325) 1 EACH TABLET:
1 EACH PO BID PRN #15
Instructions: the patient has a painful medical condition requiring treatment and this prescription is prior to her seeing pain management.
CYCLOBENZAPRINE HCL 10 MG TABLET: 10 MG PO QHS PRN #30
New Diagnostics
MR UPPER EXT JOINT W/O CON, First Available
Dx: Right shoulder pain
EVALUATION-PT, First Available
Dx: Right shoulder pain
New Referrals
Pain Management Referral
Advise
Dx: Right shoulder pain
All the above codes were used in this visit pertaining to her shoulder injury.
Can anyone point me in the right direction to see the guidelines on this?
