Well this is the dictation:
PROBLEM: Health Maintenance visit.
S: The patient si feeling okay. He still has infrequent headaches, for which he takes Maxalt and Fiorcet with success. He has tried to keep stress level down, especially in the work place.
O: Weight is 199.8 pounds. Blood pressure is 102/80. Pulse is 70. Temp is 97.5. BMI is 32. We disucssed health maintenance and patient's healthcare issue. Heart is regular rhythm. Lungs are clear. HEENT is clear. Abdomenis soft and nontender. Neurological exam is grossly within normal limits.
A: 1. Non-Gyn/health Maintenance visit
2. Hyperlipidemia.
3. Headaches
4. Depression
P 1. set up for colorectal screening colonoscopy and digital rectal exam with
prostate exam at that time.
2. lab, including CBC, BMP, Lipid< chest x-ray, AST, ALT, and PSA.
3. continue simvastatin and effexor with p.r.n nasacort and xanax.
4. TDAP update today.
So, would you still use prevenative code 99391-99397 and dx v70.0 With all the rest of diagnosis and tdap immun ?
Thanks again
MsMaddy