OK BUT IT IS QUITE EXTENSIVE
WE ALSO SAW THE PATIENT IN BETWEEN THE ABOVE DATES FOR THE HYPERTENSION, ATRIL FIB AND DM USING 99214-24 AND WE WERE PAID BY MEDICARE
THE NEXT OV ON 1/4/10 WAS MAINLY FOR THE KNEE WOUND AND NOT THE ABSCESS, BUT NOW I SEE THE DICTATION/ TRANSCRIPTION OF THE NOTES DO NOT SUPPORT THAT .. IF THE NOTES SUPPORTED THE KNEE WOUND PRIMARILY, MAYBE THE CLAIM WOULD GET PAID....
HERE IS THE 1/4/11 OV NOTE.. THANK YOU FOR YOUR INTEREST...
PT X is a 79 year Male who comes in today for OFFICE VISIT/RECHECK, Abscess, wound, Diabetes Mellitus, Paroxysmal Atrial Fibrillation (PAF), Cardiomyopathy, Hypertension, dyslipidemia and Venous Insufficiency .
Last wednesday he hit his right shin with a sander and now has a large bruise and red spot size of 1/2 dollar...Leg is swollen down to ankle. positive diabetic.
History of Present Illness
OFFICE VISIT/RECHECK
Patient is here for a 2 week follow-up visit for abscess to the left calf. Patient is also complaining of a new injury to his Rt. shin and patient's medical history is remarkable for the following:.
Abscess
The location of symptoms is in the left calf . The duration of symptoms is 1 month(s) Onset 12/06/10. The Recent medication(s) include Doxycycline and Rocephin 1 Gm IM and Efforts to treat include Incision and Drainage on 12/09/10. The symptoms of condition persists.
wound
Associated signs and symptoms include bruising and swollen ankle. The location of symptoms is in the Right shin . The duration of symptoms is 7 day(s) .
Diabetes Mellitus
The severity is mild to moderate. The symptoms of condition is chronic. The duration of symptoms is 2 year(s) . There are Recent medication(s) include Amaryl and Metformin.
Paroxysmal Atrial Fibrillation (PAF)
The severity is mild to moderate. The symptoms of condition is chronic. The duration of symptoms is significant with a long past history (20 years). There are Recent medication(s) include Digoxin and Warfarin.
Cardiomyopathy
The symptoms of condition is chronic. The duration of symptoms is significant with a long past history (20 years). There are Recent medication(s) include Coreg.
Hypertension
The severity is mild . Controlled with medication. The symptoms of condition is stable. The duration of symptoms is 5 year(s) . There are Recent medication(s) include Lisinopril; HCTZ.
dyslipidemia
The severity is mild . Controlled with medication. The symptoms of condition is chronic. The Recent medication(s) include Simvastatin. The duration of symptoms is 2 year(s) .
Venous Insufficiency
The duration of symptoms is 2 month(s) Onset 10/21/10. The Efforts to treat include compression stockings. Patient declines.
Review Of Systems
General (Constitutional) The patient denies any weight changes, changes in the way clothes fit, weakness, fever or fatigue.
Eyes Patient denies any complaints.
Ears, Nose, Mouth, Throat The patient has no complaints.
Respiratory The patient has no complaints.
Cardiovascular Patient denies any complaints.
Gastrointestinal Patient denies any complaints.
Genitourinary - Male Patient denies any complaints.
Musculoskeletal The patient complains of no complaints.
Integumentary The patient complains of non-healing wounds left lower extremity and cellulitis R leg.
Neurological Patient denies any complaints.
Past History
Medical History Medical history includes: diabetes mellitus, hypercholesterolemia, essential hypertension , Cardiomyopathy, paroxysmal atrial fibrillation and dyslipidemia.
Hospitalizations Hospitalizations include: no recent hospitalizations.
Immunizations Flu Shot - October 2008 & 09/25/09 & 10/21/10 and Pheumovax - Septemper 2009.
Examination
Skin, Hair & Nails Left Lower Extremity with non-healing abscess. Bandage removed to reveal oozing yellow discharge. Applied triple antibiotic ointment and rebandaged. Examination reveals Rt. shin distal to knee there is a golf ball size hematoma. Punctured with 18 guage needle and no pus removed. Lower leg with +severe erythema and warmth, Assessment: Cellulitis of Rt. leg and Non-healing wound of Lt. Leg, Plan: Rocephin 1 Gm IM ordered. Patient to be referred to Wuesthoff Wound Care and Patient given Rx for Doxycycline 100mg BID.
Respiratory Respirations are regular and unlabored. Lung sounds are clear in all lobes. No abnormalities noted on palpation. Resonance is noted in all fields.
Cardiovascular Auscultation reveals S1 is normal , S2 is normal , regular rate, irregular cardiac rhythm and no murmurs, rubs, or gallops.
Constitutional The patient is alert and oriented, has normal posture and motor behavior and is appropriately dressed and well-groomed. The facial expressions, manner, affect and relation to people and things are appropriate.
Extremities Examination reveals dependent edema at Rt. ankle.
Office Procedures
Diagnosis Procedures
ICD Code ICD Name Rank CPT Code CPT Name Modifiers ICD Code Units
6826 CELLULITIS OF LEG 1 96372 INJECTION:THERA,PROPH, DIAG 6826,8911 1.00
25000 DMII WO CMP NT ST UNCNTR 2 99214 OFFIC/OUTPT E&M ESTAB MODHI 25 MIN 25000,2724,4019,4254,42731,6826,8911 1.00
8911 OPEN WND KNEE/LEGCOMPL 3 J0696 Rocephin, Ceftriaxone Sodium 250 mg 6826,8911 4.00
42731 ATRIAL FIBRILLATION 4
4254 PRIM CARDIOMYOPATHY NEC 5
4019 HYPERTENSION NOS 6
2724 HYPERLIPIDEMIA NEC/NOS 7
Prescription
Medication Dosage Dispensed Qty Form Direction Start On Refill DNS
Doxycycline Tablet 100 mg 20 Tab Bid 12/06/2010 0 No
Provider does have access to a qualified e-prescribing system and some or all prescriptions generated during the encounter were printed or phoned in as required by state or federal law, patient request or pharmacy system being unable to receive electronic transmissions; or because they were for narcotics or other controlled substances.
Referral to:__________________________________
Recommendation
6826 - CELLULITIS OF LEG: The patient is advised to/ towards : Start new medication , Doxycycline.
25000 - DMII WO CMP NT ST UNCNTR: The patient is advised to/ towards : continue current meds.
8911 - OPEN WND KNEE/LEGCOMPL: Referrals : wound care center.
42731 - ATRIAL FIBRILLATION: The patient is advised to/ towards : continue current meds.
4254 - PRIM CARDIOMYOPATHY NEC: The patient is advised to/ towards : continue current meds.
4019 - HYPERTENSION NOS: The patient is advised to/ towards : continue current meds.
2724 - HYPERLIPIDEMIA NEC/NOS: The patient is advised to/ towards : continue current meds.
Follow up
01/12/2011 @3:00
Diagnostic Testing and Consults
Evaluate and treat Diagnosis : Non-healing wound to lower leg 891.1.
Instructions
The patient has had all questions answered and verbalized understanding. I have relayed that it is the patient's responsibility to return for follow-up visit as scheduled, and patient accepts full responsibility for health care in case of non-compliance with therapy and/or follow-up.
Patient encounter was documented using a CCHIT certified EHR.
