Wiki E/M or Preventive

[NESmith]

CC: Pt is here to establish care

HPI: 55 yr old female presents today to establish with new PCP.
Pt. has history of arrhythmias paroxysmal SVT and possibly SSS for which sh has a cardiac pacemaker in place. She is unsure of what her diagnoses are.
Patient has pain in her rt knee and had surgery arthroscopic done a few yrs ago but it still hurts.
Pt has essential hypertnesion for which she is on Losartan 100 mg and Hydrocholorothiazide 25 mg.
Pt had moderate to severe menopausal symptoms and is on HRT with Estradiol 1 mg once a day.
Pt has anxiety for which she is on Sertraline 50 mg of this controls it well.
Pt has allergic rhinitis and takes over-the-counter medications.
She has Hyperlipidemia and is on Simvastatin 20 mg daily.

Provider did a Complete ROS
Current Medications
Complete Histories
Complete Exam excluding Female exam.
Reviewed Previous Tests, discussed Tobacco Cessation, weight lose and vaccinations.
Ordered labs, and referrals to Cadio and Ortho.

Assessment:
Tobacco use-we discussed in detail various options for quitting smoking. She states she will think about it.
Allergic Rhinitis-stable. Continue over-the -counter antihistamines.
Paroxysmal supraventricular tachycardia-patient has a cardiologist who follows her closely for this we will obtain records.
Essential Hypertnesion-stable continue current medications
Hyperlipidemia-we will order labs.
Arthropathy of the knee/patella/tibia/fibula-this is most likely secondary to scar tissue and arthritic changes in her knee. We will continue to monitor and obtain her old records from the orthopedics.
Anxiety disorder NOS stable withsertraline continue the same.
Cardiac Pacemaker, Status Post-patient will need referral to the electrophysiologist. We will wait until her records are obtained.
Please let me know how you would code this.
Thank You.

 

[MnTwins29]

I would use preventative

There wasn't any change in the medications or treatment plans, the physician noted referrals to certain specialists, did a complete exam, physician did discuss risk factors (smoking), patient did not come with a specific complaint, but to establish care with the physician. Given this note, I would call this a preventative visit.

Just my $0.02

 

[Naveen Rachagolla]

I agree with Mn Twins because....

In CC it says the patient is here to establish care that mean at present the patient dont have any complaints.

And in the notes it says that the physician reviewed her records and moreover its he will obtain her records and he also says to continue with the current medications, the physician dint alter any medications so if the notes is like this in the assumption the coder will think that the pt has come for preventive check up which will obviously a preventive services 99381-99387