ckelder
Contributor
I am having difficulty finding the documentation to support the 99214 coded by the provider. Any suggestions would be appreciated.
CC: paperwork .
History of Present Illness:
needs paperwork..She needs her FMLA form renewed.
needs referral extended at _____. She tried to call there and was told that her referral was about to expire.
needs flu shot
needs tramadol refill
Past Medical History:
Reviewed history from 07/16/2012 and no changes required:
PCOS
Morbid obesity
Fracture right humerus
Costochondritis
Insomnia
Family History:
Reviewed history from 05/04/2012 and no changes required:
FH Hypertension
FH Diabetes
pain syndrome
Family History Coronary Heart Disease female < 65
PCOS
obesity
Social History:
Sexually Active-no
Employed
Alcohol Use - no
Drug Use - no
Living with friends
works at _____________
Risk Factors
Tobacco use: never
Review of Systems
General
Denies fatigue and malaise.
ENT
Denies sore throat.
GU Complains of dysuria.
MS
Denies back pain, stiffness, and muscle aches.
Psych
Complains of poor sleep.
Vital Signs:
Patient Profile: 25 Years Old Female
Height: 62 inches (157.48 cm)
Weight: 330.19 pounds (150.09 kg)
(Measured Weight: 330lbs. 3oz.)
BMI: 60.61
BSA: 2.37
O2 Sat: 95 %
Temp: 98.6 degrees F (37.00 degrees C) oral
Pulse rate: 100 / minute
Resp: 18 per minute
BP sitting: 136 / 83 (right arm)
Cuff size: regular
Pt. in pain? no
Vitals Entered By: __________(September 27, 2012 12:54 PM)
Body Mass Index: 60.61 Last Mammogram: 00/00/00
Last Pap Smear: 2011
Do you smoke? No
No Known Allergies
Physical Exam
General:
well developed, well nourished, in no acute distress. obese.
Head:
normocephalic and atraumatic.
Eyes:
PERRL/EOM intact, conjunctiva and sclera clear with out nystagmus.
Lungs:
clear bilaterally to auscultation.
Heart:
normal S1, S2 without murmurs, rubs, gallops, or clicks.
Skin:
intact without lesions or rashes. hirsutism
Psych:
alert and cooperative; normal mood and affect; normal attention span and concentration.
Impression & Recommendations:
Problem # 1: NEED PROPHYLACTIC VACCINATION&INOCULATION FLU (ICD-V04.81)
Flu shot today.
Orders:
Detailed LC (CPT-99214)
Fluzone 3+yrs (CPT-90658)
Problem # 2: POLYCYSTIC OVARIAN DISEASE (ICD-256.4)
Will fill out FMLA form again for another year. She needs it to have more frequent bathroom breaks.
Orders:
Detailed LC (CPT-99214)
Problem # 3: COSTOCHONDRITIS (ICD-733.6)
Will refill tramadol today.
Orders:
Detailed LC (CPT-99214)
Problem # 4: BACK PAIN (ICD-724.5)
extended referral for ___________.
The following medications were removed from the medication list:
Percocet 5-325 Mg Tabs (Oxycodone-acetaminophen) ..... Take one to two tablets every 4-6 hrs as needed
Baclofen 10 Mg Tabs (Baclofen) ..... 1 bid as needed for muscle spasm
Her updated medication list for this problem includes:
Tramadol Hcl 50 Mg Tabs (Tramadol hcl) ..... 1 bid
Other Orders:
Fluvirin (CPT-90658)
Prescriptions:
TRAMADOL HCL 50 MG TABS (TRAMADOL HCL) 1 bid #60[tablet] x 2
Patient Instructions:
1) follow up with ________ about referral.
Influenza Vaccine
Vaccine Type: Fluvirin
Date/Time: 10/01/2012 5:25 AM
Site: L deltoid
Mfr: Novartis
Dose: 0.5 ml
Route: IM
Given by: _________
Exp. Date: 05/2013
Flu Vaccine Consent Questions
Do you have a history of severe allergic reactions to this vaccine? no
Any prior history of allergic reactions to egg and/or gelatin? no
Do you have a sensitivity to the preservative Thimersol? no
Do you have a past history of Guillan-Barre Syndrome? no
Do you currently have an acute febrile illness? no
Have you ever had a severe reaction to latex? no
Vaccine information given and explained to patient? yes
Are you currently pregnant? no
CC: paperwork .
History of Present Illness:
needs paperwork..She needs her FMLA form renewed.
needs referral extended at _____. She tried to call there and was told that her referral was about to expire.
needs flu shot
needs tramadol refill
Past Medical History:
Reviewed history from 07/16/2012 and no changes required:
PCOS
Morbid obesity
Fracture right humerus
Costochondritis
Insomnia
Family History:
Reviewed history from 05/04/2012 and no changes required:
FH Hypertension
FH Diabetes
pain syndrome
Family History Coronary Heart Disease female < 65
PCOS
obesity
Social History:
Sexually Active-no
Employed
Alcohol Use - no
Drug Use - no
Living with friends
works at _____________
Risk Factors
Tobacco use: never
Review of Systems
General
Denies fatigue and malaise.
ENT
Denies sore throat.
GU Complains of dysuria.
MS
Denies back pain, stiffness, and muscle aches.
Psych
Complains of poor sleep.
Vital Signs:
Patient Profile: 25 Years Old Female
Height: 62 inches (157.48 cm)
Weight: 330.19 pounds (150.09 kg)
(Measured Weight: 330lbs. 3oz.)
BMI: 60.61
BSA: 2.37
O2 Sat: 95 %
Temp: 98.6 degrees F (37.00 degrees C) oral
Pulse rate: 100 / minute
Resp: 18 per minute
BP sitting: 136 / 83 (right arm)
Cuff size: regular
Pt. in pain? no
Vitals Entered By: __________(September 27, 2012 12:54 PM)
Body Mass Index: 60.61 Last Mammogram: 00/00/00
Last Pap Smear: 2011
Do you smoke? No
No Known Allergies
Physical Exam
General:
well developed, well nourished, in no acute distress. obese.
Head:
normocephalic and atraumatic.
Eyes:
PERRL/EOM intact, conjunctiva and sclera clear with out nystagmus.
Lungs:
clear bilaterally to auscultation.
Heart:
normal S1, S2 without murmurs, rubs, gallops, or clicks.
Skin:
intact without lesions or rashes. hirsutism
Psych:
alert and cooperative; normal mood and affect; normal attention span and concentration.
Impression & Recommendations:
Problem # 1: NEED PROPHYLACTIC VACCINATION&INOCULATION FLU (ICD-V04.81)
Flu shot today.
Orders:
Detailed LC (CPT-99214)
Fluzone 3+yrs (CPT-90658)
Problem # 2: POLYCYSTIC OVARIAN DISEASE (ICD-256.4)
Will fill out FMLA form again for another year. She needs it to have more frequent bathroom breaks.
Orders:
Detailed LC (CPT-99214)
Problem # 3: COSTOCHONDRITIS (ICD-733.6)
Will refill tramadol today.
Orders:
Detailed LC (CPT-99214)
Problem # 4: BACK PAIN (ICD-724.5)
extended referral for ___________.
The following medications were removed from the medication list:
Percocet 5-325 Mg Tabs (Oxycodone-acetaminophen) ..... Take one to two tablets every 4-6 hrs as needed
Baclofen 10 Mg Tabs (Baclofen) ..... 1 bid as needed for muscle spasm
Her updated medication list for this problem includes:
Tramadol Hcl 50 Mg Tabs (Tramadol hcl) ..... 1 bid
Other Orders:
Fluvirin (CPT-90658)
Prescriptions:
TRAMADOL HCL 50 MG TABS (TRAMADOL HCL) 1 bid #60[tablet] x 2
Patient Instructions:
1) follow up with ________ about referral.
Influenza Vaccine
Vaccine Type: Fluvirin
Date/Time: 10/01/2012 5:25 AM
Site: L deltoid
Mfr: Novartis
Dose: 0.5 ml
Route: IM
Given by: _________
Exp. Date: 05/2013
Flu Vaccine Consent Questions
Do you have a history of severe allergic reactions to this vaccine? no
Any prior history of allergic reactions to egg and/or gelatin? no
Do you have a sensitivity to the preservative Thimersol? no
Do you have a past history of Guillan-Barre Syndrome? no
Do you currently have an acute febrile illness? no
Have you ever had a severe reaction to latex? no
Vaccine information given and explained to patient? yes
Are you currently pregnant? no