aforsythe
Networker
Patient is established with the office coming in for a visit when the provider orders the patient up for a screening colonoscopy.
A 76 year old female with a history of colon polyps, a family history of colon cancer, and a personal history of hemorrhoids. Her last colonoscopy was in March 2013. She denies rectal bleeding. She has had constipation for years. She drinks more liquids with good results. She has no abdominal pain. No hear or lung disease.
All meds were reviewed and reconciled.
Past, Family, Social history documented.
Full ROS completed.
Full exam performed.
Diagnosis
Z80.0 - Family history of malignant neoplasm of digestive organs
Z86.010 - Personal history of colonic polyps
K64.0 - First degree hemorrhoids
K59.09 - Other constipation
Plan is patient to have a screening colonoscopy
We are going back and forth with whether this should be coded as a 99213 or 99214.
A 76 year old female with a history of colon polyps, a family history of colon cancer, and a personal history of hemorrhoids. Her last colonoscopy was in March 2013. She denies rectal bleeding. She has had constipation for years. She drinks more liquids with good results. She has no abdominal pain. No hear or lung disease.
All meds were reviewed and reconciled.
Past, Family, Social history documented.
Full ROS completed.
Full exam performed.
Diagnosis
Z80.0 - Family history of malignant neoplasm of digestive organs
Z86.010 - Personal history of colonic polyps
K64.0 - First degree hemorrhoids
K59.09 - Other constipation
Plan is patient to have a screening colonoscopy
We are going back and forth with whether this should be coded as a 99213 or 99214.