I am trying to determine if it would be appropriate to code a separate e/m visit in addition to the preventive visit, pertaining to the following documentation:
HPI
HPI GYN: Patient is here for an annual exam. She denies fatigue and reports a normal appetite. She denies nausea, vomiting, diarrhea, or constipation. She reports hot flashes and no problems with bladder
Menstrual cycles are not applicable
LMP hysterectomy
G4P3
She is sexually active.
Contraception: hysterectomy
She denies vaginal bleeding or pelvic pain.
She denies dysmenorrhea or dyspareunia.
Last pap smear: no abnormalities on 2011.
Discussed ASCCP guidelines for Pap screenings, Pt does not need Pap today. Pt does not request Pap Screening outside of ASCCP guidelines.
She does perform self breast exams. Her last mammogram was 5/2024 and was normal.
She had a normal Cologaurd 3 years ago.
She is taking a multi-vitamin and is exercising on a regular basis, Denies any history of domestic violence.
Vaccinations:
Flu shot Declined
Covid Vaccine received
Past medical HX: Reviewed
Past Surgical HX: Reviewed
Family HX: Reviewed
Prescribed medications reviewed uses/indications/risks/side effects and alternatives with pt and see prescription history for this visit.
CMA personally observed the physical exam performed by the provider during this office visit.
The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past family history, past medical history, past social history, past surgical history, problem list and vital signs.
Review of Systems
Constitutional: Negative.
HENT: Negative.
Respiratory: Negative.
Cardiovascular: Negative.
Gastrointestinal: Negative. Negative for abdominal distention and abdominal pain.
Endocrine: Positive for heat intolerance (hot flashes and night sweats).
Genitourinary: Positive for dyspareunia (vaginal dryness). Negative for difficulty urinating, dysuria, hematuria, pelvic pain and urgency. Menstrual problem: Hysterectomy.
Musculoskeletal: Negative.
Skin: Negative.
Lump in left armpit
Hematological: Negative.
Psychiatric/Behavioral: Negative.
Objective
Physical Exam
Vitals and nursing note reviewed. Exam conducted with a chaperone present.
Constitutional:
Appearance: She is well-developed.
HENT:
Head: Normocephalic.
Eyes:
Conjunctiva/sclera: Conjunctivae normal.
Pupils: Pupils are equal, round, and reactive to light.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Heart sounds: Normal heart sounds.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds.
Chest:
Breasts:
Breasts are symmetrical.
Right: Normal. No swelling, bleeding, inverted nipple, mass, nipple discharge, skin change or tenderness.
Left: No swelling, bleeding, inverted nipple, nipple discharge, skin change or tenderness.
Comments: 1 cm mass with irregular borders in left axilla
Abdominal:
General: Bowel sounds are normal. There is no distension.
Palpations: Abdomen is soft.
Tenderness: There is no abdominal tenderness.
Genitourinary:
Labia:
Right: No rash, tenderness, lesion or injury.
Left: No rash, tenderness, lesion or injury.
Vagina: Normal. No vaginal discharge.
Rectum: Normal.
Comments: Uterus surgically absent, no adnexal masses.
Pale tissues
Musculoskeletal:
General: Normal range of motion.
Cervical back: Normal range of motion.
Skin:
General: Skin is warm and dry.
Neurological:
Mental Status: She is alert and oriented to person, place, and time.
Psychiatric:
Behavior: Behavior normal.
Thought Content: Thought content normal.
Judgment: Judgment normal.
Vitals
Vitals:
07/29/24 0856
BP: 102/78
Weight: 144 lb 12.8 oz (65.7 kg)
Height: 5' 3.5"
Assessment & Plan
Well woman exam with routine gynecological exam
Mass of left axilla
- US BREAST LIMITED LEFT; Future
Menopausal symptoms
- estradioL (ESTRACE) 0.5 MG tablet; Take 1 tablet (0.5 mg total) by mouth daily.
1. Pt has been made aware that Her MYCHART is available for results. She will be notified by phone for abnormal results.
2. Pap today No per ASCCP Guidelines.
3. Patient would like to continue all practice prescribed medications for another year.
4. All Risk, benefits, complications, alternative and instructions for the prescribed medications were discussed. Pt verbalized understanding.
5. Patient Counseling:
--Nutrition: Stressed importance of moderation in sodium/caffeine intake, saturated fat and cholesterol, caloric balance, sufficient intake of fresh fruits, vegetables, fiber, calcium, iron, and 1 mg of folate supplement per day (for females capable of pregnancy).
--Exercise: Stressed the importance of regular exercise.
--Substance Abuse: Discussed cessation/primary prevention of tobacco, alcohol, or other drug use; driving or other dangerous activities under the influence; availability of treatment for abuse.
--Sexuality: Discussed sexually transmitted diseases, partner selection, use of condoms, avoidance of unintended pregnancy and contraceptive alternatives.
--Dental health: Discussed importance of dental visits.
--Immunizations reviewed.
--Covid Vaccine Up to date and/or opportunity to vaccinate discussed. Appropriate Information Provided
6. Discussed the patient's BMI with her. The BMI Body mass index is 25.25 kg/m².
7. Encouraged Mammogram yearly and monthly breast exams.
8. Offer Lipid profile, TSH, HGB A1c q5yrs
9. Colon cancer screening discussed and encouraged.
Previously well tolerated estrace for menopausal symptoms, well controlled HTN on meds now and would like to resume. Risks and expectations reviewed.
Await imaging on left axilla mass, normal mammo on 5/24
RTC 2-3 months for med check
HPI
HPI GYN: Patient is here for an annual exam. She denies fatigue and reports a normal appetite. She denies nausea, vomiting, diarrhea, or constipation. She reports hot flashes and no problems with bladder
Menstrual cycles are not applicable
LMP hysterectomy
G4P3
She is sexually active.
Contraception: hysterectomy
She denies vaginal bleeding or pelvic pain.
She denies dysmenorrhea or dyspareunia.
Last pap smear: no abnormalities on 2011.
Discussed ASCCP guidelines for Pap screenings, Pt does not need Pap today. Pt does not request Pap Screening outside of ASCCP guidelines.
She does perform self breast exams. Her last mammogram was 5/2024 and was normal.
She had a normal Cologaurd 3 years ago.
She is taking a multi-vitamin and is exercising on a regular basis, Denies any history of domestic violence.
Vaccinations:
Flu shot Declined
Covid Vaccine received
Past medical HX: Reviewed
Past Surgical HX: Reviewed
Family HX: Reviewed
Prescribed medications reviewed uses/indications/risks/side effects and alternatives with pt and see prescription history for this visit.
CMA personally observed the physical exam performed by the provider during this office visit.
The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past family history, past medical history, past social history, past surgical history, problem list and vital signs.
Review of Systems
Constitutional: Negative.
HENT: Negative.
Respiratory: Negative.
Cardiovascular: Negative.
Gastrointestinal: Negative. Negative for abdominal distention and abdominal pain.
Endocrine: Positive for heat intolerance (hot flashes and night sweats).
Genitourinary: Positive for dyspareunia (vaginal dryness). Negative for difficulty urinating, dysuria, hematuria, pelvic pain and urgency. Menstrual problem: Hysterectomy.
Musculoskeletal: Negative.
Skin: Negative.
Lump in left armpit
Hematological: Negative.
Psychiatric/Behavioral: Negative.
Objective
Physical Exam
Vitals and nursing note reviewed. Exam conducted with a chaperone present.
Constitutional:
Appearance: She is well-developed.
HENT:
Head: Normocephalic.
Eyes:
Conjunctiva/sclera: Conjunctivae normal.
Pupils: Pupils are equal, round, and reactive to light.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Heart sounds: Normal heart sounds.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds.
Chest:
Breasts:
Breasts are symmetrical.
Right: Normal. No swelling, bleeding, inverted nipple, mass, nipple discharge, skin change or tenderness.
Left: No swelling, bleeding, inverted nipple, nipple discharge, skin change or tenderness.
Comments: 1 cm mass with irregular borders in left axilla
Abdominal:
General: Bowel sounds are normal. There is no distension.
Palpations: Abdomen is soft.
Tenderness: There is no abdominal tenderness.
Genitourinary:
Labia:
Right: No rash, tenderness, lesion or injury.
Left: No rash, tenderness, lesion or injury.
Vagina: Normal. No vaginal discharge.
Rectum: Normal.
Comments: Uterus surgically absent, no adnexal masses.
Pale tissues
Musculoskeletal:
General: Normal range of motion.
Cervical back: Normal range of motion.
Skin:
General: Skin is warm and dry.
Neurological:
Mental Status: She is alert and oriented to person, place, and time.
Psychiatric:
Behavior: Behavior normal.
Thought Content: Thought content normal.
Judgment: Judgment normal.
Vitals
Vitals:
07/29/24 0856
BP: 102/78
Weight: 144 lb 12.8 oz (65.7 kg)
Height: 5' 3.5"
Assessment & Plan
Well woman exam with routine gynecological exam
Mass of left axilla
- US BREAST LIMITED LEFT; Future
Menopausal symptoms
- estradioL (ESTRACE) 0.5 MG tablet; Take 1 tablet (0.5 mg total) by mouth daily.
1. Pt has been made aware that Her MYCHART is available for results. She will be notified by phone for abnormal results.
2. Pap today No per ASCCP Guidelines.
3. Patient would like to continue all practice prescribed medications for another year.
4. All Risk, benefits, complications, alternative and instructions for the prescribed medications were discussed. Pt verbalized understanding.
5. Patient Counseling:
--Nutrition: Stressed importance of moderation in sodium/caffeine intake, saturated fat and cholesterol, caloric balance, sufficient intake of fresh fruits, vegetables, fiber, calcium, iron, and 1 mg of folate supplement per day (for females capable of pregnancy).
--Exercise: Stressed the importance of regular exercise.
--Substance Abuse: Discussed cessation/primary prevention of tobacco, alcohol, or other drug use; driving or other dangerous activities under the influence; availability of treatment for abuse.
--Sexuality: Discussed sexually transmitted diseases, partner selection, use of condoms, avoidance of unintended pregnancy and contraceptive alternatives.
--Dental health: Discussed importance of dental visits.
--Immunizations reviewed.
--Covid Vaccine Up to date and/or opportunity to vaccinate discussed. Appropriate Information Provided
6. Discussed the patient's BMI with her. The BMI Body mass index is 25.25 kg/m².
7. Encouraged Mammogram yearly and monthly breast exams.
8. Offer Lipid profile, TSH, HGB A1c q5yrs
9. Colon cancer screening discussed and encouraged.
Previously well tolerated estrace for menopausal symptoms, well controlled HTN on meds now and would like to resume. Risks and expectations reviewed.
Await imaging on left axilla mass, normal mammo on 5/24
RTC 2-3 months for med check
