samyjm13
Guru
I code for an Internal Med clinic, and I am struggling with a providers Routine followup with no complaints, almost always, mostly maintainence. Usually Medicare or Med Advant.
He wants to code 99214, I need a little instructions or advise. Below is a progress note that are similar what he does on "rountine followup encounters".
XXX is a 75-year-old female here in the clinic for routine follow-up of her multiple chronic medical conditions including DM II, HTN, hyperlipidemia, atrial fibrillation, OSA, asthma, and hypothyroidism, and gout. She reports that she has been doing well overall since the time of her last visit. We focused today's visit on the following:
DM I/II-- HBA1C and Urine Microalbumin as noted below. XXXXX reports that her last hemoglobin A1c at Humphreys was 6%. XXXX has been monitoring her blood sugars 3-4 times per day. She continues to follow regularly at the Humphrey's Diabetic Education Center for insulin adjustments. Her average a.m. readings have been around 120. Average prelunch readings have been 160. Average predinner readings have been around 150. Average prebedtime readings have been around 120.. She sees her ophthalmologist, Dr. xxxx, once every 12 months.
ATRIAL FIBRILLATION/HISTORY OF SINUS NODE DYSFUNCTION-- XXXXX follows intermittently with her cardiologist, Dr. xxxxx. Her pacemaker is felt to be functioning appropriately. She denies any chest pain, palpitations, or presyncopal symptoms.
HYPERTENSION--XXXXX reports that her blood pressure readings have been in the normal range when she checks, which is basically only at various medical appointments. She denies any chest pain or palpitations.
LOWER EXTREMITY EDEMA-- XXXXX has a history of chronic intermittent lower extremity edema. She has previously been prescribed lower extremity compression stockings, however has not been able to use these for quite some time as she has significant difficulty getting them on and off. Her last echocardiogram completed in December, 2009 showed an estimated ejection fraction of 60-65% with possible mild pulmonary hypertension. She remains on low-dose Lasix and potassium supplementation, which she believes has been quite helpful. She denies any PND, or orthopnea. She reports that Dr. XXXXX discontinue her hydrochlorothiazide at the time of her last visit, which resulted in significant increase in peripheral edema, therefore she restarted this medication on her own. She reports that her edema subsequently resolved.
HYPERLIPIDEMIA-- XXXXX continues to refuse any additional lipid-lowering evaluation/treatment.
OBSTRUCTIVE SLEEP APNEA-- XXXXX has a history of obstructive sleep apnea. She started CPAP therapy in July, 2010, but subsequently became frustrated with using this. She was fitted for an oral appliance which she started in May, 2011. She has been following with XXXXXXX Idaho Pulmonary and was started on nocturnal oxygen supplementation. She has found this to be very beneficial. She follows with her pulmonology/sleep medicine specialist, Dr. xxxxxx, as recommended.
ASTHMA/ALLERGIC RHINITIS-- Evelyn has been taking Flonase on an as needed basis. She reports minimal allergy symptoms recently. She has not been taking Flovent or albuterol recently.
OSTEOPENIA-- DEXA (1/2011): T-Scores -1.5 Spine/-1.9 Hip. FRAX 10-year probabiltiy for fracture 9.9% major osteoporotic and 2.1% hip. She reports adequate calcium and vitamin D supplementation. Vitamin D level 30 (6.2012).
HYPOTHYROIDISM-- TSH 0.61 (2/2012). She reports excellent compliance with Synthroid therapy.
RECURRENT UTIS-- She denies any interval UTI's since her last visit.
GOUT-- She denies interval gout flares. She has been tolerating allopurinol well.
Lab Results
Component Value Date
WBC 9.2 6/5/2012
HGB 16.8* 6/5/2012
HCT 51.8* 6/5/2012
PLT 306 6/5/2012
ALT 41 6/5/2012
AST 38 6/5/2012
NA 144 6/5/2012
K 4.5 6/5/2012
CL 101 6/5/2012
CREATININE 1.23* 6/5/2012
BUN 33* 6/5/2012
CO2 30.5 6/5/2012
INR 3* 12/14/2012
HGBA1C 6.6* 6/5/2012
MICROALBUR <10.00 6/5/2012
The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past medical history, past social history, past surgical history and problem list.
Review of Systems
As outlined in the HPI.
Objective:
Physical Exam
Constitutional: She appears well-developed and well-nourished. Non-toxic appearance. She does not appear ill. No distress.
HENT:
Head: Normocephalic and atraumatic.
Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal.
Neck: Carotid bruit is not present. No mass and no thyromegaly present.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no gallop.
No murmur heard.
No peripheral edema
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress.
Skin: No cyanosis. Nails show no clubbing.
Feet: No concerning lesions/ulcers/fissures, sensation intact to monofilament testing. First toenails are surgically absent bilaterally.
Assessment:
1. Diabetes mellitus type I
2. Atrial fibrillation
3. OSA (obstructive sleep apnea)
4. CKD (chronic kidney disease), stage III
5. Lower extremity edema
6. Hypothyroidism (acquired)
7. Asthma
8. Osteopenia
9. Allergic rhinitis
10. Recurrent UTI
11. History of skin cancer
12. History of malignant neoplasm of female breast
Plan:
Diabetes mellitus type I
Relevant Hx: s/p partial pancreatectomy at age 38
Daily Update: Doing well overall
Today's Plan:
1. Continue current insulin regimen + Humphreys follow-up as recommended.
2. Ophthalmologic examinations per Dr. XXXX
3. Daily feet inspections
4. Healthy diabetic eating
5. Check Labs
HTN (hypertension)
Daily Update: Doing well on current regimen.
Today's Plan:
1. Continue Losartan, HCTZ, and Toprol
2. I recommended intermittent home BP monitoring
3. Call if readings are consistently > 130/80
Atrial fibrillation + H/O Sinus Node Dysfunction
Daily Update: Stable on current regimen.
Today's Plan:
1. Continue current regimen + follow-up with Dr. XXXXX as recommended.
2. Coumadin management per ACC.
OSA (obstructive sleep apnea)
Relevant Hx: Severe, on oral appliance (intolerant of CPAP) + nocturnal oxygen supplementation. Sleep Medicine physician is Dr. XXXX (previously Dr. XXX).
Daily Update: Reportedly doing well on current regimen.
Today's Plan:
1. Management per Sleep Medicine.
2. Continue oral appliance + nocturnal oxygen supplementation
CKD (chronic kidney disease), stage III
Daily Update: Stable.
Today's Plan:
1. Continue ARB.
Lower extremity edema
Relevant Hx: She has a history of chronic intermittent lower extremity edema. She has previously been prescribed lower extremity compression stockings, however has not been able to use these for quite some time as she has significant difficulty getting them on and off. Her last echocardiogram completed in December, 2009 showed an estimated ejection fraction of 60-65% with possible mild pulmonary hypertension
Daily Update: Stable on current regimen. Evelyn reports significant progression off HCTZ therapy, which she subsequently restarted.
Today's Plan:
1. Continue Lasix + Potassium
2. Healthy low-salt eating
Hypothyroidism (acquired)
Daily Update: TSH 0.61 (2/12).
Today's Plan:
1. Continue Levothyroxine
2. Check TSH
Asthma
Daily Update: Minimal symptoms. Not using Flovent. Rare Albuterol.
Today's Plan:
1. Continue current regimen.
2. Call if progressive symptoms, questions, or concerns.
Allergic rhinitis
Daily Update: Well-controlled.
Today's Plan:
1. Continue Flonase PRN.
History of malignant neoplasm of female breast
Relevant Hx: Breast Cancer 1995: Lumpectomy, Radiation.
Daily Update: Denies any new/suspicious breast changes.
Today's Plan:
1. Annual mammogram and clinical breast exam are up to date
Osteopenia
Relevant Hx: DEXA (1/2011): T-Socres -1.5 Spine/-1.9 Hip. FRAX 10-year probabiltiy for fracture 9.9% major osteoporotic and 2.1% hip.
Daily Update: Vit D 30 (6/2012)
Today's Plan:
1. Continue Calcium + Vit D
Recurrent UTI
Relevant Hx: History of recurrent UTI's and multiple antibiotic allergies.
Daily Update: No interval UTI's
Today's Plan:
1. Schedule appointment and provide urine sample if recurrent symptoms.
GOUT
Relevant Hx: History of multiple gout attacks. Uric Acid 9.6 at time of diagnosis.
Daily Update: No interval gout attacks. Uric Acid 5.4 (11/2012).
Today's Plan:
1. Continue Allopurinol
He wants to code 99214, I need a little instructions or advise. Below is a progress note that are similar what he does on "rountine followup encounters".
XXX is a 75-year-old female here in the clinic for routine follow-up of her multiple chronic medical conditions including DM II, HTN, hyperlipidemia, atrial fibrillation, OSA, asthma, and hypothyroidism, and gout. She reports that she has been doing well overall since the time of her last visit. We focused today's visit on the following:
DM I/II-- HBA1C and Urine Microalbumin as noted below. XXXXX reports that her last hemoglobin A1c at Humphreys was 6%. XXXX has been monitoring her blood sugars 3-4 times per day. She continues to follow regularly at the Humphrey's Diabetic Education Center for insulin adjustments. Her average a.m. readings have been around 120. Average prelunch readings have been 160. Average predinner readings have been around 150. Average prebedtime readings have been around 120.. She sees her ophthalmologist, Dr. xxxx, once every 12 months.
ATRIAL FIBRILLATION/HISTORY OF SINUS NODE DYSFUNCTION-- XXXXX follows intermittently with her cardiologist, Dr. xxxxx. Her pacemaker is felt to be functioning appropriately. She denies any chest pain, palpitations, or presyncopal symptoms.
HYPERTENSION--XXXXX reports that her blood pressure readings have been in the normal range when she checks, which is basically only at various medical appointments. She denies any chest pain or palpitations.
LOWER EXTREMITY EDEMA-- XXXXX has a history of chronic intermittent lower extremity edema. She has previously been prescribed lower extremity compression stockings, however has not been able to use these for quite some time as she has significant difficulty getting them on and off. Her last echocardiogram completed in December, 2009 showed an estimated ejection fraction of 60-65% with possible mild pulmonary hypertension. She remains on low-dose Lasix and potassium supplementation, which she believes has been quite helpful. She denies any PND, or orthopnea. She reports that Dr. XXXXX discontinue her hydrochlorothiazide at the time of her last visit, which resulted in significant increase in peripheral edema, therefore she restarted this medication on her own. She reports that her edema subsequently resolved.
HYPERLIPIDEMIA-- XXXXX continues to refuse any additional lipid-lowering evaluation/treatment.
OBSTRUCTIVE SLEEP APNEA-- XXXXX has a history of obstructive sleep apnea. She started CPAP therapy in July, 2010, but subsequently became frustrated with using this. She was fitted for an oral appliance which she started in May, 2011. She has been following with XXXXXXX Idaho Pulmonary and was started on nocturnal oxygen supplementation. She has found this to be very beneficial. She follows with her pulmonology/sleep medicine specialist, Dr. xxxxxx, as recommended.
ASTHMA/ALLERGIC RHINITIS-- Evelyn has been taking Flonase on an as needed basis. She reports minimal allergy symptoms recently. She has not been taking Flovent or albuterol recently.
OSTEOPENIA-- DEXA (1/2011): T-Scores -1.5 Spine/-1.9 Hip. FRAX 10-year probabiltiy for fracture 9.9% major osteoporotic and 2.1% hip. She reports adequate calcium and vitamin D supplementation. Vitamin D level 30 (6.2012).
HYPOTHYROIDISM-- TSH 0.61 (2/2012). She reports excellent compliance with Synthroid therapy.
RECURRENT UTIS-- She denies any interval UTI's since her last visit.
GOUT-- She denies interval gout flares. She has been tolerating allopurinol well.
Lab Results
Component Value Date
WBC 9.2 6/5/2012
HGB 16.8* 6/5/2012
HCT 51.8* 6/5/2012
PLT 306 6/5/2012
ALT 41 6/5/2012
AST 38 6/5/2012
NA 144 6/5/2012
K 4.5 6/5/2012
CL 101 6/5/2012
CREATININE 1.23* 6/5/2012
BUN 33* 6/5/2012
CO2 30.5 6/5/2012
INR 3* 12/14/2012
HGBA1C 6.6* 6/5/2012
MICROALBUR <10.00 6/5/2012
The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past medical history, past social history, past surgical history and problem list.
Review of Systems
As outlined in the HPI.
Objective:
Physical Exam
Constitutional: She appears well-developed and well-nourished. Non-toxic appearance. She does not appear ill. No distress.
HENT:
Head: Normocephalic and atraumatic.
Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal.
Neck: Carotid bruit is not present. No mass and no thyromegaly present.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no gallop.
No murmur heard.
No peripheral edema
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress.
Skin: No cyanosis. Nails show no clubbing.
Feet: No concerning lesions/ulcers/fissures, sensation intact to monofilament testing. First toenails are surgically absent bilaterally.
Assessment:
1. Diabetes mellitus type I
2. Atrial fibrillation
3. OSA (obstructive sleep apnea)
4. CKD (chronic kidney disease), stage III
5. Lower extremity edema
6. Hypothyroidism (acquired)
7. Asthma
8. Osteopenia
9. Allergic rhinitis
10. Recurrent UTI
11. History of skin cancer
12. History of malignant neoplasm of female breast
Plan:
Diabetes mellitus type I
Relevant Hx: s/p partial pancreatectomy at age 38
Daily Update: Doing well overall
Today's Plan:
1. Continue current insulin regimen + Humphreys follow-up as recommended.
2. Ophthalmologic examinations per Dr. XXXX
3. Daily feet inspections
4. Healthy diabetic eating
5. Check Labs
HTN (hypertension)
Daily Update: Doing well on current regimen.
Today's Plan:
1. Continue Losartan, HCTZ, and Toprol
2. I recommended intermittent home BP monitoring
3. Call if readings are consistently > 130/80
Atrial fibrillation + H/O Sinus Node Dysfunction
Daily Update: Stable on current regimen.
Today's Plan:
1. Continue current regimen + follow-up with Dr. XXXXX as recommended.
2. Coumadin management per ACC.
OSA (obstructive sleep apnea)
Relevant Hx: Severe, on oral appliance (intolerant of CPAP) + nocturnal oxygen supplementation. Sleep Medicine physician is Dr. XXXX (previously Dr. XXX).
Daily Update: Reportedly doing well on current regimen.
Today's Plan:
1. Management per Sleep Medicine.
2. Continue oral appliance + nocturnal oxygen supplementation
CKD (chronic kidney disease), stage III
Daily Update: Stable.
Today's Plan:
1. Continue ARB.
Lower extremity edema
Relevant Hx: She has a history of chronic intermittent lower extremity edema. She has previously been prescribed lower extremity compression stockings, however has not been able to use these for quite some time as she has significant difficulty getting them on and off. Her last echocardiogram completed in December, 2009 showed an estimated ejection fraction of 60-65% with possible mild pulmonary hypertension
Daily Update: Stable on current regimen. Evelyn reports significant progression off HCTZ therapy, which she subsequently restarted.
Today's Plan:
1. Continue Lasix + Potassium
2. Healthy low-salt eating
Hypothyroidism (acquired)
Daily Update: TSH 0.61 (2/12).
Today's Plan:
1. Continue Levothyroxine
2. Check TSH
Asthma
Daily Update: Minimal symptoms. Not using Flovent. Rare Albuterol.
Today's Plan:
1. Continue current regimen.
2. Call if progressive symptoms, questions, or concerns.
Allergic rhinitis
Daily Update: Well-controlled.
Today's Plan:
1. Continue Flonase PRN.
History of malignant neoplasm of female breast
Relevant Hx: Breast Cancer 1995: Lumpectomy, Radiation.
Daily Update: Denies any new/suspicious breast changes.
Today's Plan:
1. Annual mammogram and clinical breast exam are up to date
Osteopenia
Relevant Hx: DEXA (1/2011): T-Socres -1.5 Spine/-1.9 Hip. FRAX 10-year probabiltiy for fracture 9.9% major osteoporotic and 2.1% hip.
Daily Update: Vit D 30 (6/2012)
Today's Plan:
1. Continue Calcium + Vit D
Recurrent UTI
Relevant Hx: History of recurrent UTI's and multiple antibiotic allergies.
Daily Update: No interval UTI's
Today's Plan:
1. Schedule appointment and provide urine sample if recurrent symptoms.
GOUT
Relevant Hx: History of multiple gout attacks. Uric Acid 9.6 at time of diagnosis.
Daily Update: No interval gout attacks. Uric Acid 5.4 (11/2012).
Today's Plan:
1. Continue Allopurinol