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#1
08-20-2012, 04:32 PM
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New Patient Visit
Provider has chosen 99203 but when I work this up I come up with 99202.
CC: Anxiety. History of Present Illness: pt recently had major life change. she is having increased anxiety and panic attacks. she has been celexa in the past and this has worked well. she denies any depression or suicidal ideation. she has been having insomnia. Risk Factors: Review of Systems See HPI Vital Signs: Patient Profile: Years Old Female Height: 61 inches Weight: 97.5 pounds BMI: 18.49 Temp: 97.5 degrees F tympanic Pulse rate: 104 / minute Pulse rhythm: regular BP sitting: 152 / 80 (left arm) Cuff size: regular Vitals Entered By: Physical Exam General: well developed, well nourished, in no acute distress. Lungs: clear bilaterally to auscultation. Heart: non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops Psych: anxious. Impression & Recommendations: Problem # 1: ANXIETY (ICD-300.00) will get records and follow up in two weeks. Her updated medication list for this problem includes: Celexa 40 Mg Tabs (Citalopram hydrobromide) ..... One tab po daily Alprazolam 1 Mg Tabs (Alprazolam) ..... One tab po bid prn Medications Added to Medication List This Visit: 1) Micardis Hct 80-25 Mg Tabs (Telmisartan-hctz) .... 1 po qd 2) Lipitor 80 Mg Tabs (Atorvastatin calcium) .... 1 po qd 3) Aspirin 81 Mg Tabs (Aspirin) .... 1 po qd 4) Celexa 40 Mg Tabs (Citalopram hydrobromide) .... One tab po daily 5) Alprazolam 1 Mg Tabs (Alprazolam) .... One tab po bid prn Prescriptions: ALPRAZOLAM 1 MG TABS (ALPRAZOLAM) one tab po bid prn #30 x 0 Entered and Authorized by: 447-1104 CELEXA 40 MG TABS (CITALOPRAM HYDROBROMIDE) one tab po daily #30 x 5 Entered and Authorized by: 
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#3
08-22-2012, 10:23 AM
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its 99202 hx EPF... PE EPF.. MDM moderate........
no chance of 99203...
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