snjberry
Networker
CC: Concerns
History of Present Illness
HEALTHCARE MAINTENANCE:
Accompanied by: Mom ().
15 year old male apparently found with inappropriate contact with a 6 year old girl 2 days ago. reports touching her outside of her clothes in her private areas; mom reports that the girl's mother, "came downstairs and found him dry humping her." No other information forthcoming.adamantly denies touching any parts of skin under clothing, that the little girl touched any part of him including outside of clothing or inside of clothing.
Long history of Emotional/Behavioral issues, last seen 3/20/15 (182 lbs). Had been on Strattera 40mg PO QAM, "but we stop it during the summer," says . Completed grade 8 in 8:1:1 program with at ?.
HIV Screening* (13-64 yo) Offered 07/15/2015 Declined. Flu shot* Administered 12/04/2014. Tdap Date 09/09/2011. DEPRESSION SCREENING PHQ 2/9 Screening 07/15/2015.
Current Medications
Not-Taking/PRNStrattera 40 mg Capsule 1 capsule in the morning Once a day
Past Medical History
Adhd
Learning difficulty
Surgical History
none
Family History
No Family History documented.
Social History
Tobacco Use:
Smoking Are you a:: never smoker .
Household:
Mother: .
lives with both parents and sister.
Allergies
N.K.D.A.
Hospitalization/Major Diagnostic Procedure
none
Vital Signs
Temp 98.5, HR 68, RR 14, Wt 167, Ht 69, BMI 24.66, BMI Percentile 90.15.
Examination
Pediatric Male:
GENERAL: well developed, well nourished, in no distress, quite self conscious, contrite.
Assessments
1. ODD (oppositional defiant disorder) - 313.81 (Primary)
2. Attention deficit disorder with hyperactivity - 314.01
Inappropriate Contact with a Minor.
Treatment
1. ODD (oppositional defiant disorder)
Notes: Mental Health evaluation/intervention (note given, mom to arrange).
2. Attention deficit disorder with hyperactivity
Notes: Ongoing ADHD/ODD care.
3. Others
Notes: Counseled (reviewing appropriate boundaries, responsibility for to deal with his sexuality a way that in no way involved minors or is inappropriate in any way).
Preventive Medicine
Anticipatory Guidance: Office visit-total face to face time with provider (of which 1/2 of more in counseling) 25 min.
Disposition & Communication
Visit summary given to patient: Yes
So my dilemma is that this visit is not related to ADHD or ODD and should be coded as sexual counseling / concerns. I also spoke with QA Director who agreed with me. I then sent email to provider who states it was the above conditions that led to his behavior and that's why they were coded and not the reason for visit. Any help would be appreciated. Am I way off base or what would you code??? No current discussion in HPI or ROS or Exam on ADHD issues, or ODD other than to say history of. which should be in history section of the note
Thank you
History of Present Illness
HEALTHCARE MAINTENANCE:
Accompanied by: Mom ().
15 year old male apparently found with inappropriate contact with a 6 year old girl 2 days ago. reports touching her outside of her clothes in her private areas; mom reports that the girl's mother, "came downstairs and found him dry humping her." No other information forthcoming.adamantly denies touching any parts of skin under clothing, that the little girl touched any part of him including outside of clothing or inside of clothing.
Long history of Emotional/Behavioral issues, last seen 3/20/15 (182 lbs). Had been on Strattera 40mg PO QAM, "but we stop it during the summer," says . Completed grade 8 in 8:1:1 program with at ?.
HIV Screening* (13-64 yo) Offered 07/15/2015 Declined. Flu shot* Administered 12/04/2014. Tdap Date 09/09/2011. DEPRESSION SCREENING PHQ 2/9 Screening 07/15/2015.
Current Medications
Not-Taking/PRNStrattera 40 mg Capsule 1 capsule in the morning Once a day
Past Medical History
Adhd
Learning difficulty
Surgical History
none
Family History
No Family History documented.
Social History
Tobacco Use:
Smoking Are you a:: never smoker .
Household:
Mother: .
lives with both parents and sister.
Allergies
N.K.D.A.
Hospitalization/Major Diagnostic Procedure
none
Vital Signs
Temp 98.5, HR 68, RR 14, Wt 167, Ht 69, BMI 24.66, BMI Percentile 90.15.
Examination
Pediatric Male:
GENERAL: well developed, well nourished, in no distress, quite self conscious, contrite.
Assessments
1. ODD (oppositional defiant disorder) - 313.81 (Primary)
2. Attention deficit disorder with hyperactivity - 314.01
Inappropriate Contact with a Minor.
Treatment
1. ODD (oppositional defiant disorder)
Notes: Mental Health evaluation/intervention (note given, mom to arrange).
2. Attention deficit disorder with hyperactivity
Notes: Ongoing ADHD/ODD care.
3. Others
Notes: Counseled (reviewing appropriate boundaries, responsibility for to deal with his sexuality a way that in no way involved minors or is inappropriate in any way).
Preventive Medicine
Anticipatory Guidance: Office visit-total face to face time with provider (of which 1/2 of more in counseling) 25 min.
Disposition & Communication
Visit summary given to patient: Yes
So my dilemma is that this visit is not related to ADHD or ODD and should be coded as sexual counseling / concerns. I also spoke with QA Director who agreed with me. I then sent email to provider who states it was the above conditions that led to his behavior and that's why they were coded and not the reason for visit. Any help would be appreciated. Am I way off base or what would you code??? No current discussion in HPI or ROS or Exam on ADHD issues, or ODD other than to say history of. which should be in history section of the note
Thank you