Help , I have a Provider that is trying to bill a 99395
Can some please advise does these meet the DG for a Prevenative Medicine. Please see the following EHR Note .
Chief Complaint
check up
History of Present Illness
REVIEW OF PAST HISTORY:
Past Medical History Reviewed and Updated - see history section.
Past Surgical History Reviewed and Updated - see history section.
Past Social History Reviewed and Updated - see history section.
Medications and Supplements were Reviewed and Updated.
Free Text HPI: Pt going to school in CA, has not seen a doctor in about 1 yr. Pt has noticed black spots on skin, randomly, for past month. Had on both hands last week, comes and goes, no itching. No new creams, lotions, detergents.
Past Medical History
No significant previous past medical history.
Surgical History
No previous surgical history.
Family History
· Family history of Family Health Status Of Father - Good
· Family history of Family Health Status Of Mother - Good
· Family history of Family Health Status Siblings ___ Living All In Good Health
Social History
· Never A Smoker
· Never Drank Alcohol
Denied
· History of Drug Use
Allergies
No Known Drug Allergies
Current Meds
1. Ciprofloxacin HCl - 500 MG Oral Tablet; TAKE 1 TABLET EVERY 12 HOURS DAILY; Therapy:
01Aug2011 to (Evaluate:08Aug2011); Last Rx:01Aug2011
2. Phenazopyridine HCl - 200 MG Oral Tablet; TAKE 1 TABLET 3 TIMES DAILY AS NEEDED FOR PAIN;
Therapy: 01Aug2011 to (Evaluate:05Aug2011); Last Rx:01Aug2011
Active Problems
1. Gross Hematuria 599.71
2. Pain During Urination (Dysuria) 788.1
3. Urinary Tract Infection 599.0
Review of Systems
Constitutional:.
No fevers, chills, or night sweats.
Eyes:.
No blurred or double vission and no spots or changes in visual fields..
ENT:.
No headache, ear, nose or throat pain, or nasal discharge..
Hematologic/Lymphatic:.
No gland swelling.
Cardiovascular:.
No chest pain or pressure and no palpitations.
Respiratory:.
No Dyspnea or wheezing.
Gastrointestinal:
No abdominal pain, nausea, vomiting, diarrhea, or constipation..
Genitourinary:.
No dysuria, hematuria, nocturia, urine frequency, incontinence..
Musculoskeletal:.
No joint pain, stiffness, swelling, or redness..
Endocrine:.
No fatigue.
No flushing, heat or cold intolerance, or hair loss.
Allergy/Immunology:.
No Itching or Sneezing.
Integumentary:.
No itching or jaundice.
Other Symptoms:
LMP 3/25/13.
Vitals
26Mar2013 10:35AM
Temperature 98.8 F
Heart Rate 98
Systolic 100
Diastolic 60
BMI Calculated 24.98
BSA Calculated 1.59
Height 5 ft 1 in
Weight 132 lb 5 oz
O2 Saturation 98
Physical Exam
Constitutional
General appearance is normal.
Eyes
PERRLA, EOM Intact, and conjunctiva and sclera clear.
Head, Ears, Nose, Mouth and Throat
TM's and canals clear bilaterally.
Nasal mucosa clear and with out edema or exudate.
Throat clear with out exudates and oral mucosa moist.
No neck masses.
Lymphatic
No significant lymphadenopathy or lymphatic tenderness.
Cardiovascular
Rate and rhythm are normal and no murmurs, gallops, or rubs noted.
Color Pink, no cyanosis.
Upper and lower extremity pulses symmetric and normal.
Pulmonary
Lungs clear to auscultation without wheezing or rhonchi.
Breath sounds are equal.
No respiratory distress.
Abdomen
Abdomen is flat, soft, NABS, no organomegaly or masses.
No Abdominal tenderness, rebound, or guarding.
No abdominal hernias.
Musculoskeletal
No back or neck spinal or muscle tenderness, No muscle spasticity.
No joint tenderness, edema, or diminished ROM.
Upper Extremity Exam was Normal.
Lower Extremity Exam was Normal.
No lower extremity EDEMA.
Neurologic
No abnormalities in sensation.
No abnormalities in gait coordination.
Reflexes present and symmetric.
Cranial Nerves Intact.
Motor Exam Normal.
Skin
No abnormal rashes, lesions, or ulcerations.
No lacerations, abrasions, or contusions.
Normal turgor.
Psychiatric
Alert, Oriented to Person Place and Time, Speech is clear, Grooming appropriate.
Assessment
1. Health Maintenance V70.0
Plan
Health Maintenance (V70.0)
· LC CMP14+LP+TSH Requested for: 26Mar2013
· LC Vitamin B12 and Folate Requested for: 26Mar2013
· LC Vitamin D, 25-Hydroxy Requested for: 26Mar2013
Check labs, tx as indicated. Dark spots may be do to bruising or trauma. Monitor for changes. Follow up again when has spot.
Level of Service
99395 Adult 18-39
Can some please advise does these meet the DG for a Prevenative Medicine. Please see the following EHR Note .
Chief Complaint
check up
History of Present Illness
REVIEW OF PAST HISTORY:
Past Medical History Reviewed and Updated - see history section.
Past Surgical History Reviewed and Updated - see history section.
Past Social History Reviewed and Updated - see history section.
Medications and Supplements were Reviewed and Updated.
Free Text HPI: Pt going to school in CA, has not seen a doctor in about 1 yr. Pt has noticed black spots on skin, randomly, for past month. Had on both hands last week, comes and goes, no itching. No new creams, lotions, detergents.
Past Medical History
No significant previous past medical history.
Surgical History
No previous surgical history.
Family History
· Family history of Family Health Status Of Father - Good
· Family history of Family Health Status Of Mother - Good
· Family history of Family Health Status Siblings ___ Living All In Good Health
Social History
· Never A Smoker
· Never Drank Alcohol
Denied
· History of Drug Use
Allergies
No Known Drug Allergies
Current Meds
1. Ciprofloxacin HCl - 500 MG Oral Tablet; TAKE 1 TABLET EVERY 12 HOURS DAILY; Therapy:
01Aug2011 to (Evaluate:08Aug2011); Last Rx:01Aug2011
2. Phenazopyridine HCl - 200 MG Oral Tablet; TAKE 1 TABLET 3 TIMES DAILY AS NEEDED FOR PAIN;
Therapy: 01Aug2011 to (Evaluate:05Aug2011); Last Rx:01Aug2011
Active Problems
1. Gross Hematuria 599.71
2. Pain During Urination (Dysuria) 788.1
3. Urinary Tract Infection 599.0
Review of Systems
Constitutional:.
No fevers, chills, or night sweats.
Eyes:.
No blurred or double vission and no spots or changes in visual fields..
ENT:.
No headache, ear, nose or throat pain, or nasal discharge..
Hematologic/Lymphatic:.
No gland swelling.
Cardiovascular:.
No chest pain or pressure and no palpitations.
Respiratory:.
No Dyspnea or wheezing.
Gastrointestinal:
No abdominal pain, nausea, vomiting, diarrhea, or constipation..
Genitourinary:.
No dysuria, hematuria, nocturia, urine frequency, incontinence..
Musculoskeletal:.
No joint pain, stiffness, swelling, or redness..
Endocrine:.
No fatigue.
No flushing, heat or cold intolerance, or hair loss.
Allergy/Immunology:.
No Itching or Sneezing.
Integumentary:.
No itching or jaundice.
Other Symptoms:
LMP 3/25/13.
Vitals
26Mar2013 10:35AM
Temperature 98.8 F
Heart Rate 98
Systolic 100
Diastolic 60
BMI Calculated 24.98
BSA Calculated 1.59
Height 5 ft 1 in
Weight 132 lb 5 oz
O2 Saturation 98
Physical Exam
Constitutional
General appearance is normal.
Eyes
PERRLA, EOM Intact, and conjunctiva and sclera clear.
Head, Ears, Nose, Mouth and Throat
TM's and canals clear bilaterally.
Nasal mucosa clear and with out edema or exudate.
Throat clear with out exudates and oral mucosa moist.
No neck masses.
Lymphatic
No significant lymphadenopathy or lymphatic tenderness.
Cardiovascular
Rate and rhythm are normal and no murmurs, gallops, or rubs noted.
Color Pink, no cyanosis.
Upper and lower extremity pulses symmetric and normal.
Pulmonary
Lungs clear to auscultation without wheezing or rhonchi.
Breath sounds are equal.
No respiratory distress.
Abdomen
Abdomen is flat, soft, NABS, no organomegaly or masses.
No Abdominal tenderness, rebound, or guarding.
No abdominal hernias.
Musculoskeletal
No back or neck spinal or muscle tenderness, No muscle spasticity.
No joint tenderness, edema, or diminished ROM.
Upper Extremity Exam was Normal.
Lower Extremity Exam was Normal.
No lower extremity EDEMA.
Neurologic
No abnormalities in sensation.
No abnormalities in gait coordination.
Reflexes present and symmetric.
Cranial Nerves Intact.
Motor Exam Normal.
Skin
No abnormal rashes, lesions, or ulcerations.
No lacerations, abrasions, or contusions.
Normal turgor.
Psychiatric
Alert, Oriented to Person Place and Time, Speech is clear, Grooming appropriate.
Assessment
1. Health Maintenance V70.0
Plan
Health Maintenance (V70.0)
· LC CMP14+LP+TSH Requested for: 26Mar2013
· LC Vitamin B12 and Folate Requested for: 26Mar2013
· LC Vitamin D, 25-Hydroxy Requested for: 26Mar2013
Check labs, tx as indicated. Dark spots may be do to bruising or trauma. Monitor for changes. Follow up again when has spot.
Level of Service
99395 Adult 18-39