Wiki Physicals/Preventative Documentation

[coding4fun]

Can you guys offer a website which will outline the exact format for a physical/preventative exam. Opinion on the below to see if you agree/disagree on meeting for yearly exam.

SUBJECTIVE: a 54 year old here for routine wellness visit. He is w/o any major complaints. No chest pain, shortness of breath, bowel or bladder problems. No lighheaded spells. Trying to get more active. jhe has been trying to watch his diet. Medication remain the same. labs reviewed.

Past medical history is unchanged.

Social history is stable. Former smoker but not currently.

OBJECTIVE: Weight is 202 pounds, up 5 pounds. BP is 140/90 and 152/86. Pulse if 80. He is alert and in no acute distress. Face is symmetric. Speech is clear. Affect is normal. Carotids are without bruits. Thyroid is normal. Lungs are clear. Heart has regular rate and rhythm. No pitting edema. No calf tenderness or cords. Grip strenth is symmetric.

ASSESSMENT:
1. Hypertension
2. Huyperlipidemia
3. Gout

 

[rryder1963]

Preventive Medicine Services

SUBJECTIVE: a 54 year old here for routine wellness visit. He is w/o any major complaints. No chest pain, shortness of breath, bowel or bladder problems. No lighheaded spells. Trying to get more active. jhe has been trying to watch his diet. Medication remain the same. labs reviewed.

Past medical history is unchanged.

Social history is stable. Former smoker but not currently.

OBJECTIVE: Weight is 202 pounds, up 5 pounds. BP is 140/90 and 152/86. Pulse if 80. He is alert and in no acute distress. Face is symmetric. Speech is clear. Affect is normal. Carotids are without bruits. Thyroid is normal. Lungs are clear. Heart has regular rate and rhythm. No pitting edema. No calf tenderness or cords. Grip strenth is symmetric.

ASSESSMENT:
1. Hypertension
2. Huyperlipidemia
3. Gout

Per CPT 2014: "The extent and focus of the services will largely depend on the age of the patient. The "comprehensive" nature of the Preventive Medicine Services codes 99381-99397 reflects an age and gender appropriate history/exam and is not synonymous with the "comprehensive" examination in the E/M codes 99201-99350. Preventive medicine codes also include counseling/anticipatory guidance/risk factor reduction and interventions."
That being noted, what meds is the patient taking and for what and for how long? "Past medical history is unchanged" and "Social history is stable" do not count as elements because there are no dates of previous documents in the patient's medical record for us to refer to. I would hard pressed to bill out any level of E/M based on this documentation.
Jeannie