Elund
Networker
The documentation:
Why is 96372 reported in addition to J0696, which already specifies that the drug was injected?
Family Practice USA
Dr. John Jones
AGE: 40
Sex: F
DOS: 10/01/20XX
Progress Note
Subjective: Patient is a new patient in the office today. She is seen in the office for follow up. Last Wednesday she became ill with right lower quadrant abdominal pain. She was initially seen at the emergency room and a CT scan was done. They told her that her pain was due to a ruptured ovarian cyst. Three days later she presented to the emergency room with continued right lower quadrant abdominal pain and was told there was not any evidence of any cyst of fluid in her abdomen. She was told that she had bacterial vaginosis and treated her with Flagyl which she has not started. She was given Percocet for pain which does help. We have reviewed the medical record from the emergency room visit. A pelvic ultrasound was done. She had clue cells on the examination. The pelvic ultrasound was normal. They reported in the records that they did a bacterial culture, but we tried to contact them for the results an apparently the culture was not submitted or not performed. She denies any nausea, vomiting, diarrhea or constipation. She denies and dysuria, hesitancy or incontinence. She denies any vaginal discharge.
Medications: She takes no medications on a regular basis.
Allergies: She has no known allergies.
Past Personal History: Negative for any health problems. Last menstrual period was normal. Menses is regular. Birth control includes tubal ligation.
Previous History of Hospitalizations/Surgeries: She has had a previous tubal ligation and C-section. Otherwise negative.
Objective:
Physical Exam: Weight: 121 lbs; Height: 5’2; T: 98.4; BP: 90/70; P: 108; RESPIRATIONS: 16; PULSE OX: 97%. The patient appears to be in pain. She does not appear to be acutely ill. ABDOMEN: soft and tender in the right lower quadrant. There is no rebound or guarding. She has normoactive bowel sounds. HEART: RRR, without murmurs, clicks or rubs. LUNGS: clear to auscultation, without rales, rhonchi or wheezing. She is well-hydrated and well-nourished, not jaundiced.
Assessment: Right lower quadrant pain compatible with PID.
Plan:
Order: Injection, intramuscular with Rocephin 500 done today
Since culture was not done, we elected to go ahead and treat her with Rocephin 500 mg IM, in office today, which was given Zithromax 500 mg 1 q.d. for 3 days and asked her to get the Flagyl. We did write a prescription for Lortab 7.5 #30 one q. 6 hours p.r.n. pain. She needs to notify her sexual contact, which is her fiancé. We want to follow her again in a week or as needed sooner. We recommend she return to the emergency room if the pain became more intense.
John Jones, MD
Electronically signed by JOHN JONES, MD 10/01/20XX
Dr. John Jones
AGE: 40
Sex: F
DOS: 10/01/20XX
Progress Note
Subjective: Patient is a new patient in the office today. She is seen in the office for follow up. Last Wednesday she became ill with right lower quadrant abdominal pain. She was initially seen at the emergency room and a CT scan was done. They told her that her pain was due to a ruptured ovarian cyst. Three days later she presented to the emergency room with continued right lower quadrant abdominal pain and was told there was not any evidence of any cyst of fluid in her abdomen. She was told that she had bacterial vaginosis and treated her with Flagyl which she has not started. She was given Percocet for pain which does help. We have reviewed the medical record from the emergency room visit. A pelvic ultrasound was done. She had clue cells on the examination. The pelvic ultrasound was normal. They reported in the records that they did a bacterial culture, but we tried to contact them for the results an apparently the culture was not submitted or not performed. She denies any nausea, vomiting, diarrhea or constipation. She denies and dysuria, hesitancy or incontinence. She denies any vaginal discharge.
Medications: She takes no medications on a regular basis.
Allergies: She has no known allergies.
Past Personal History: Negative for any health problems. Last menstrual period was normal. Menses is regular. Birth control includes tubal ligation.
Previous History of Hospitalizations/Surgeries: She has had a previous tubal ligation and C-section. Otherwise negative.
Objective:
Physical Exam: Weight: 121 lbs; Height: 5’2; T: 98.4; BP: 90/70; P: 108; RESPIRATIONS: 16; PULSE OX: 97%. The patient appears to be in pain. She does not appear to be acutely ill. ABDOMEN: soft and tender in the right lower quadrant. There is no rebound or guarding. She has normoactive bowel sounds. HEART: RRR, without murmurs, clicks or rubs. LUNGS: clear to auscultation, without rales, rhonchi or wheezing. She is well-hydrated and well-nourished, not jaundiced.
Assessment: Right lower quadrant pain compatible with PID.
Plan:
Order: Injection, intramuscular with Rocephin 500 done today
Since culture was not done, we elected to go ahead and treat her with Rocephin 500 mg IM, in office today, which was given Zithromax 500 mg 1 q.d. for 3 days and asked her to get the Flagyl. We did write a prescription for Lortab 7.5 #30 one q. 6 hours p.r.n. pain. She needs to notify her sexual contact, which is her fiancé. We want to follow her again in a week or as needed sooner. We recommend she return to the emergency room if the pain became more intense.
John Jones, MD
Electronically signed by JOHN JONES, MD 10/01/20XX
Why is 96372 reported in addition to J0696, which already specifies that the drug was injected?