dorinda05
Networker
Need clarification on this coding: This was a new patient visit with no prominent PMH who simply wanted a checkup. Please see the documentation below. My question is, this is a new patient-no prior records were reviewed-our physician sends the patient for basic labs. The only complaint the patient had was fatigue. Now, my instinct says the code this as a physical CPT w/ ICD's of Z00.00 & R53.83-THAT'S IT! My provider lists out the diagnosis' that she presumes the patient has based on his statement of "fatigue" on the lab ORDERS and my encounter for the office visit but these diagnosis' have not been confirmed yet. Am I correct in my thinking that her presumption of what the labs will read CANNOT be billed on the current encounter below OR the lab orders? Should her reason for the orders be Z00.00 & R53.83? Any insight on this will be appreciated!
Patient Intake
Chief Complaint
Chief Complaint: Establish Care
Allergies
Allergies:
Coded Allergies:
No Known Drug Allergies (Verified Allergy, 1/18/17)
Vitals
Vitals:
Height 5 ft 8 in / 172.72 cm
Weight 227 lbs / 102.965 kg
BSA 2.26 m2
BMI 34.5 kg/m2
Temperature 98.3 F / 36.83 C - Oral (Reference: 36.3 - 37.3 C)
Pulse 67 (Reference: 60 - 100)
Respirations 16 (Reference: 12 - 20)
Blood Pressure 120/80 Sitting, Right Arm (Reference: 90/60 - 140/90)
Pulse Oximetry 97%, room air
Medication List
Medications Last Reconciled on 1/18/17 10:06 by ***
WAS MED LIST OBTAINED?: No (PER PATIENT MEMORY )
Tobacco Status
Tobacco status: Never smoker
Tobacco details: Other (N/A)
Counseling given: Other (N/A)
Tobacco use screen in last 30: No
Past, Family, & Social History
Past Medical History
Last reviewed 1/18/17
Patient reports no known history of significant medical conditions.
Family History
Last reviewed 1/18/17
33 FATHER
Lung cancer
Social History
Last reviewed 1/18/17
Social History
Adopted No
Foster care No
Lives independently Yes
Sexual activity Yes
Diet and Exercise
Caffeinated beverage intake Coke Zero, Rockstars
Exercise Frequency 3-4 times
Exercise Duration 60-90 minutes/day
Tobacco Use
Smoking packs/day 0
Alcohol Use
Alcohol intake socially
Substance Use
Substance use Denies use
Surgical History
Last reviewed 1/18/17
Arm surgery (left arm, plates and screws)
HPI-Family Practice
History of Present Illness
Details
Patient presents today to Establish Care. Patient does not have a regular pcp and does not remember last time he was seen. No labs have been done. He is just wanting a "general check-up".
Notes takes Tylenol and Ibuprofen OTC PRN and does have some Fatigue and possible HLD in the past; Also notes was previously Pre-Hypertensive with BP. Patient is a Financial Adviser at Merrill Lynch.
ROS-Family Practice
Details
see HPI **
Constitutional: COMPLAINS OF: Fatigue, DENIES: Appetite change, Excessive sweating, Fever, Night sweats, Weight gain, Weight loss
Eyes: DENIES: Blurred vision, Corrective lenses, Diplopia, Eye irritation, Eye pain, Spots in vision, Vision loss
Ears, nose, mouth, throat: DENIES: Bleeding gums, Dental pain, Ear pain, Facial pain, Hearing loss, Hoarseness, Mouth lesions, Nasal discharge, Nasal obstruction, Nosebleeds, Postnasal drainage, Sore throat, Tinnitus, Vertigo
Cardiovascular: DENIES: Chest pain, Claudication, Decr. exercise tolerance, Exertional dyspnea, Leg ulcers, Orthopnea, Palpitations, Peripheral edema, Syncope
Respiratory: DENIES: Apneas, Cough, Hemoptysis, Pleuritic pain, Shortness of breath, Snoring, Sputum production, Wheezing
Gastrointestinal: DENIES: Abdominal pain, Black stools, Bloating, Bloody stools, Change in bowel habits, Constipation, Diarrhea, Dysphagia, Food intolerance, Nausea, Reflux/heartburn, Vomiting
Genitourinary: DENIES: Change in urinary stream, Dysuria, Hematuria, Incontinence, Nocturia, Penile discharge, Sexual dysfunction, Urinary frequency, Urinary urgency
Musculoskeletal: DENIES: Back pain, Joint pain, Joint swelling, Limited range of motion, Muscle aches, Muscle weakness, Stiffness
Integumentary: DENIES: Hair changes, Lesions/changes in moles, Nail changes, Pigment changes, Pruritus, Rash
Neurologic: DENIES: Abnormal gait, Focal weakness, Headache, Incoordination, Memory problems, Numbness, Seizures, Slurred speech, Tremor
Psychiatric: DENIES: Anxiety, Decreased concentration, Irritability, Panic attacks, Sadness/tearfulness, Sleep disturbances
Endocrine: DENIES: Polydipsia, Polyphagia, Polyuria
Hematologic/lymphatic: DENIES: Bleeding tendencies, Bruising, Lymphadenopathy, Recurrent infections
Allergic/immunologic: DENIES: Eczema, Seasonal allergies, Urticaria
EXAM-Family Practice
Constitutional
Details
Well developed, well nourished, very pleasant in NAD,
General appearance: comfortable
Nutritional status: overweight
Orientation: alert and oriented x3
HEENT
Details
PERL, Sclera anicteric, Fundi show sharp disc margins without any AV hemmorages, nicks or exudates, normal cup to disc ratio, no papiledema, sharp disc margins,eyelids are without ptosis, no nystagmas, no dermatocholasis, no xanthomas. Mallampatti I OP.
Neck
Details
Neck supple, FROM, no thyromegaly, no thyroid bruit, no thyroid nodules, no JVD, normal Jugular waveforms, no tracheal deviation. No lymphadenopathy, Carotids show normal upstroke and volume. No carotid bruits.
COR
Details
no heaves or thrills, the PMI is medial to the midclavicular line, fourth ICS. Auscultation reveals S1, S2 of normal intensity. No S3, S4, rubs, clicks, or other abnormal heart sounds. Rate is regular.
Thorax
Details
Thorax is symmetric. Full expansion is noted bilaterally. A/P diameter is within normal limits. Lung fields are resonant throughout. There are no adventitial sounds.
Back
Details
Normal cervical and lumbar lordosis are present, there is no scoliosis, kyphosis or paraspinal muscle tenderness or spasm present. Full range of motion for flexion, extension, lateral rotation, lateral flexion and extension are present.
Abdominal
Details
Abdomen is soft and non-tender, liver percusses to approximately 10 cm in the right MCL. The spleen tip is not palpable, there are no abdominal masses, no hernias, there are no capillary dilatations, no skin lesions noted. Auscultation reveals normoactive bowel sounds. No guarding or masses. There are no bruits, the abdominal aorta is not enlarged to palpation and is not pulsatile.
Extremities
Details
No cervical/lumbar/sacral tenderness
Breast Exam
Chest appearance: normal
Genitalia
CVA tenderness: none
GU exam deferred: Yes
Rectal
Rectal exam deferred: Yes
Skin
Skin: FINDINGS: normal color
Hair: normal
DEFERRED SKIN EXAM: Yes
Neuro
Details
CN III - XII grossly intact. Speech, memory, and expression are within normal limits. Muscle strength is 5/5 in both upper and lower extremities.There is no muscle atrophy or involuntary movement noted. Testing of cerebellar function reveals normal gait. Sensory is intact to light touch. There are no focal motor/sensory deficits present. Deep tendon reflexes are 2+ and equal bilaterally for patellar, ankle and biceps.
Musculoskeletal
Details
Psychiatric
Mental status: grossly normal
Affect: normal
Judgment: normal (Insight is Good. )
Assessment/Plan
Assessment/Plan:
1. Encounter for long-term (current) use of other medications ( patient is not on any meds nor was any script written????)
2. Hyperlipidemia (why, because the patient mentioned "possible HLD?)
3. Fatigue (this is legitimate)
4. Anemia (nothing to base this diagnosis off of)
5. Vitamin B 12 deficiency (nothing to base this diagnosis off of)see Orders
see Notes
see HPI
New Diagnostics
COMPREHENSIVE METABOLIC PANEL, First Available
Dx: Encounter for long-term (current) use of other medications
LIPID PANEL, First Available
Dx: Hyperlipidemia
TSH, First Available
Dx: Fatigue
CBC WITH AUTO DIFF, First Available
Dx: Anemia
VITAMIN B12, First Available
Dx: Vitamin B 12 deficiencyPatient instructions
Adverse reactions and side effects of all medications were discussed with the patient fully and a time was allowed for questions and all questions were answered completely to the patient's satisfaction. The patient was in full agreement with the plan of care. Follow up was arranged in two week's time, sooner for progressive problems or interval complaints. Should the patient develop questions they will call or set up a sooner appointment. They will return to the office if they should experience any adverse reactions or side effects with any of the medications.
Education resources provided: No
Tobacco Counselling Given?: No
Patient Intake
Chief Complaint
Chief Complaint: Establish Care
Allergies
Allergies:
Coded Allergies:
No Known Drug Allergies (Verified Allergy, 1/18/17)
Vitals
Vitals:
Height 5 ft 8 in / 172.72 cm
Weight 227 lbs / 102.965 kg
BSA 2.26 m2
BMI 34.5 kg/m2
Temperature 98.3 F / 36.83 C - Oral (Reference: 36.3 - 37.3 C)
Pulse 67 (Reference: 60 - 100)
Respirations 16 (Reference: 12 - 20)
Blood Pressure 120/80 Sitting, Right Arm (Reference: 90/60 - 140/90)
Pulse Oximetry 97%, room air
Medication List
Medications Last Reconciled on 1/18/17 10:06 by ***
WAS MED LIST OBTAINED?: No (PER PATIENT MEMORY )
Tobacco Status
Tobacco status: Never smoker
Tobacco details: Other (N/A)
Counseling given: Other (N/A)
Tobacco use screen in last 30: No
Past, Family, & Social History
Past Medical History
Last reviewed 1/18/17
Patient reports no known history of significant medical conditions.
Family History
Last reviewed 1/18/17
33 FATHER
Lung cancer
Social History
Last reviewed 1/18/17
Social History
Adopted No
Foster care No
Lives independently Yes
Sexual activity Yes
Diet and Exercise
Caffeinated beverage intake Coke Zero, Rockstars
Exercise Frequency 3-4 times
Exercise Duration 60-90 minutes/day
Tobacco Use
Smoking packs/day 0
Alcohol Use
Alcohol intake socially
Substance Use
Substance use Denies use
Surgical History
Last reviewed 1/18/17
Arm surgery (left arm, plates and screws)
HPI-Family Practice
History of Present Illness
Details
Patient presents today to Establish Care. Patient does not have a regular pcp and does not remember last time he was seen. No labs have been done. He is just wanting a "general check-up".
Notes takes Tylenol and Ibuprofen OTC PRN and does have some Fatigue and possible HLD in the past; Also notes was previously Pre-Hypertensive with BP. Patient is a Financial Adviser at Merrill Lynch.
ROS-Family Practice
Details
see HPI **
Constitutional: COMPLAINS OF: Fatigue, DENIES: Appetite change, Excessive sweating, Fever, Night sweats, Weight gain, Weight loss
Eyes: DENIES: Blurred vision, Corrective lenses, Diplopia, Eye irritation, Eye pain, Spots in vision, Vision loss
Ears, nose, mouth, throat: DENIES: Bleeding gums, Dental pain, Ear pain, Facial pain, Hearing loss, Hoarseness, Mouth lesions, Nasal discharge, Nasal obstruction, Nosebleeds, Postnasal drainage, Sore throat, Tinnitus, Vertigo
Cardiovascular: DENIES: Chest pain, Claudication, Decr. exercise tolerance, Exertional dyspnea, Leg ulcers, Orthopnea, Palpitations, Peripheral edema, Syncope
Respiratory: DENIES: Apneas, Cough, Hemoptysis, Pleuritic pain, Shortness of breath, Snoring, Sputum production, Wheezing
Gastrointestinal: DENIES: Abdominal pain, Black stools, Bloating, Bloody stools, Change in bowel habits, Constipation, Diarrhea, Dysphagia, Food intolerance, Nausea, Reflux/heartburn, Vomiting
Genitourinary: DENIES: Change in urinary stream, Dysuria, Hematuria, Incontinence, Nocturia, Penile discharge, Sexual dysfunction, Urinary frequency, Urinary urgency
Musculoskeletal: DENIES: Back pain, Joint pain, Joint swelling, Limited range of motion, Muscle aches, Muscle weakness, Stiffness
Integumentary: DENIES: Hair changes, Lesions/changes in moles, Nail changes, Pigment changes, Pruritus, Rash
Neurologic: DENIES: Abnormal gait, Focal weakness, Headache, Incoordination, Memory problems, Numbness, Seizures, Slurred speech, Tremor
Psychiatric: DENIES: Anxiety, Decreased concentration, Irritability, Panic attacks, Sadness/tearfulness, Sleep disturbances
Endocrine: DENIES: Polydipsia, Polyphagia, Polyuria
Hematologic/lymphatic: DENIES: Bleeding tendencies, Bruising, Lymphadenopathy, Recurrent infections
Allergic/immunologic: DENIES: Eczema, Seasonal allergies, Urticaria
EXAM-Family Practice
Constitutional
Details
Well developed, well nourished, very pleasant in NAD,
General appearance: comfortable
Nutritional status: overweight
Orientation: alert and oriented x3
HEENT
Details
PERL, Sclera anicteric, Fundi show sharp disc margins without any AV hemmorages, nicks or exudates, normal cup to disc ratio, no papiledema, sharp disc margins,eyelids are without ptosis, no nystagmas, no dermatocholasis, no xanthomas. Mallampatti I OP.
Neck
Details
Neck supple, FROM, no thyromegaly, no thyroid bruit, no thyroid nodules, no JVD, normal Jugular waveforms, no tracheal deviation. No lymphadenopathy, Carotids show normal upstroke and volume. No carotid bruits.
COR
Details
no heaves or thrills, the PMI is medial to the midclavicular line, fourth ICS. Auscultation reveals S1, S2 of normal intensity. No S3, S4, rubs, clicks, or other abnormal heart sounds. Rate is regular.
Thorax
Details
Thorax is symmetric. Full expansion is noted bilaterally. A/P diameter is within normal limits. Lung fields are resonant throughout. There are no adventitial sounds.
Back
Details
Normal cervical and lumbar lordosis are present, there is no scoliosis, kyphosis or paraspinal muscle tenderness or spasm present. Full range of motion for flexion, extension, lateral rotation, lateral flexion and extension are present.
Abdominal
Details
Abdomen is soft and non-tender, liver percusses to approximately 10 cm in the right MCL. The spleen tip is not palpable, there are no abdominal masses, no hernias, there are no capillary dilatations, no skin lesions noted. Auscultation reveals normoactive bowel sounds. No guarding or masses. There are no bruits, the abdominal aorta is not enlarged to palpation and is not pulsatile.
Extremities
Details
No cervical/lumbar/sacral tenderness
Breast Exam
Chest appearance: normal
Genitalia
CVA tenderness: none
GU exam deferred: Yes
Rectal
Rectal exam deferred: Yes
Skin
Skin: FINDINGS: normal color
Hair: normal
DEFERRED SKIN EXAM: Yes
Neuro
Details
CN III - XII grossly intact. Speech, memory, and expression are within normal limits. Muscle strength is 5/5 in both upper and lower extremities.There is no muscle atrophy or involuntary movement noted. Testing of cerebellar function reveals normal gait. Sensory is intact to light touch. There are no focal motor/sensory deficits present. Deep tendon reflexes are 2+ and equal bilaterally for patellar, ankle and biceps.
Musculoskeletal
Details
Psychiatric
Mental status: grossly normal
Affect: normal
Judgment: normal (Insight is Good. )
Assessment/Plan
Assessment/Plan:
1. Encounter for long-term (current) use of other medications ( patient is not on any meds nor was any script written????)
2. Hyperlipidemia (why, because the patient mentioned "possible HLD?)
3. Fatigue (this is legitimate)
4. Anemia (nothing to base this diagnosis off of)
5. Vitamin B 12 deficiency (nothing to base this diagnosis off of)see Orders
see Notes
see HPI
New Diagnostics
COMPREHENSIVE METABOLIC PANEL, First Available
Dx: Encounter for long-term (current) use of other medications
LIPID PANEL, First Available
Dx: Hyperlipidemia
TSH, First Available
Dx: Fatigue
CBC WITH AUTO DIFF, First Available
Dx: Anemia
VITAMIN B12, First Available
Dx: Vitamin B 12 deficiencyPatient instructions
Adverse reactions and side effects of all medications were discussed with the patient fully and a time was allowed for questions and all questions were answered completely to the patient's satisfaction. The patient was in full agreement with the plan of care. Follow up was arranged in two week's time, sooner for progressive problems or interval complaints. Should the patient develop questions they will call or set up a sooner appointment. They will return to the office if they should experience any adverse reactions or side effects with any of the medications.
Education resources provided: No
Tobacco Counselling Given?: No
