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Old 09-18-2009, 04:15 AM
Vikas Maheshwari Vikas Maheshwari is offline
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Default Please suggest the code

i am thinking to provide these CPT for the following service can anyone suggest i am correct for the particular scenario or not

99393
90700
90707
90713




a 5 year old boy who is an established patient brought in for 5 year well-child visit.

HPI
INTERVAL HISTORY:
DIET: Eats well-balanced meals, fruits, vegetables, and milk on a daily basis.
ELIMINATION: Voiding and stooling without concerns. No chronic diarrhea nor constipation.
SLEEP: Sleeps well at night without concerns.
DEVELOPMENT: Counts, imaginary play, knows colors, skips/hops, dresses self, recognizes ABC's, copies triangle.
IMMUNIZATION STATUS: No prior allergic reactions.
TB RISK FACTORS: None.
PARENTAL CONCERNS: None.
Family Hx
Benign.
Allergies
No Known Drug Allergy.
Vital Signs
HR: 117 b/min,
Resp: 22 r/min,
Temp: 97.9 F,
Height: 43.5 in, Weight: 51.4 lb, BMI: 19.1 kg/m2,
O2 Sat: 100 (%SpO2).
Vision Screening:
Unable to cooperate.

Audio Screening: 25 db HL
+ Right ear response: 500 Hz: Yes
1000 Hz: Yes
2000 Hz: Yes
4000 Hz: Yes
+ Left ear response: 500 Hz: Yes
1000 Hz: Yes
2000 Hz: Yes
4000 Hz: Yes.
Physical Exam
GROWTH PARAMETERS: Normal growth curves, see growth flowsheet. BMI normal
GENERAL: Well developed, well nourished, and in no acute distress.
SKIN: No rash, no lesions.
HEENT: Head: Normocephalic and atraumatic. Eyes: Positive bilateral red reflex. Extraocular muscles intact. PERRL. Funduscopic exam normal. Normal eyelids, conjunctavae and sclera. Ears: Bilateral canals and tympanic membranes clear. Normal appearance to pinna. Nose: Patent, normal external appearance to nose. Normal nasal mucosa, septum and turbinates. Oropharynx: Moist mucous membranes. Normal palate, no lesions. Normal dentition. Normal gums and lips.
NECK: Supple. No lymphadenopathy. Normal tone. Thyroid normal without enlargement, tenderness or masses.
RESPIRATORY: Clear to auscultation throughout all lung fields.
HEART: Normal S1 and S2. Regular rate and rhythm. No murmur.
ABDOMEN: Soft and nontender. No hepatosplenomegaly. No masses. Normal bowel sounds in all four quadrants.
BACK: No spinal deformities. No evidences of scoliosis.
EXTREMITIES: Warm and well perfused. No clubbing, cyanosis or edema. Normal gait.
GU: Tanner 1 normal. Testes bilaterally descended and no evidence of hernia.
NEUROLOGIC: Alert. Motor 5/5 upper and lower extremities symmetrically.
Assessment
5 years old for well child check.
Plan
Immunizations:.
Safety and anticipatory guidance regarding: car/booster seat safety, poisening safety, nutrition, household safety, helmets, dental visits, strangers/touching, pool safety, firearm safety, no passive smoking & street safety; all discussed at length with caregiver who expresses understanding.
Follow up labs. Recheck vision and followup in clinic in one month or sooner p.r.n. any other problems or concerns.
__________________
Vikas Maheshwari
Operation Manager (Medical Billing & Coding)
MBA-HCS, CPC-H
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