Here is an example where the provider is coding a 99214, and its a new patient, so I know this is wrong, and I think it should be a 99203. Can someone give me their opinion on what they think. Thank you.
CC:
Referred for Lymph node biopsy
HPI:
Patient had noticed enlargement of lymph nodes in the neck and had CT scan done that showed generalized lymph nodes in chest axilla and groins. He was seen by provider ? and underwent bone marrow biopsy and was advised lymph node biopsy.
He denies pain, fever. weight loss.
No family h/o malignancy.
ALLERGIES:
No Known Allergies Confirmed -
Allergy list reviewed. updated
CURRENT MEDICATIONS:
Medications List Reviewed
Medication list reviewed. updated
PAST MEDICAL HISTORY:
Past Medical History Reviewed updated
The patient has a past medical history of Hypertension, Diabetes Mellitus type 2, Hyperlipidemia.
Other past medical history includes chronic lymphocytic leukemia OF B CELL TYPE.
No recent change in medical history. updated
SURGICAL HISTORY:
Previous surgery includes bilateral hip replacement X 2
SOCIAL HISTORY:
Smoking Status: Never smoker
Tobacco User: No
No counseling on tobacco cessation
Rx therapy for tobacco cessation
Did not discuss Smoking/Tobacco Use Cessation Strategies
Alcohol use: Non-Drinker
Social History Reviewed updated
FAMILY HISTORY:
Family History Reviewed updated
PREVENTIVE CARE:
Colonoscopy:
REVIEW OF SYSTEMS:
General:
No constitutional symptoms.
No fatigue, no fever, no chills, no weight loss.
Neck:
Small lymph nodes both posterior neck..
Cardiovascular:
no cardiovascular symptoms.
Respiratory:
no respiratory symptoms.
Gastrointestinal:
No GI symptoms.
Genitourinary:
no gu symptoms.
Musculoskeletal:
no musculoskeletal symptoms.
Hip pain.
Neurologic
no neurologic symptoms.
Psychologic:
no psych symptoms.
VITAL SIGNS:
Were taken
PHYSICAL EXAMINATION:
General:
alert, oriented to time, place and person, well nourished, in no acute distress.
Neck:
Bilateral small posterior triangle nodes. Non tender.
Lymphatics:
Bilateral axillary and groin palpable nodes. All are soft non tender.
IMAGING STUDIES:
CT Scan:
Generalized lymphadenopathy
ASSESSMENT:
GENERALIZED LYMPHADENOPATHY. R/O MALIGNANT LYMPHOMA.
DIABETES.
HYPERTENSION
PLAN:
Excision biopsy left axillary lymph node.
Discussed with patient.