avrilw
Networker
Will someone please review this chart note and let me know if we should bill a 99212 or 99213 and give me a breakdown of the rationale? Thanks!
CC: personal conerns.
History of Present Illness:
In for evaluation of lump in her vaginal area. States at this point it has pretty much gone away after being present for about a year. Not tender or red. No abnormal vaginal discharge.
Has a fluttering or pulsing sensation in the left side of her chest that comes and goes. Sometimes also gets it in her eyelid. No pain or shortness of breath.
Vital Signs:
Patient Profile: 14 Years & 7 Months Old Female
Height: 67 inches (131.83 cm)
Weight: 135.5 pounds
BMI: 21.30
BSA: 1.72
Temp: 97.6 degrees F temporal
Pulse rate: 68 / minute
Pulse rhythm: regular
BP sitting: 106 / 68 (left arm)
Cuff size: regular
Vitals Entered By: Brianne Watson MA (January 29, 2014 3:44 PM)
Physical Exam
General:
Well appearing adolescent,no acute distress
Genitalia:
normal female; tiny papule at posterior right labia- not tender or erythematous- ?cystic
Musculoskeletal:
left lateral chest wall nontender
Impression & Recommendations:
Problem # 1: SKIN LESION (ICD-709.9)
possibly ingrown hair or small cyst- reassurance given; call if grows or becomes bothersome
CC: personal conerns.
History of Present Illness:
In for evaluation of lump in her vaginal area. States at this point it has pretty much gone away after being present for about a year. Not tender or red. No abnormal vaginal discharge.
Has a fluttering or pulsing sensation in the left side of her chest that comes and goes. Sometimes also gets it in her eyelid. No pain or shortness of breath.
Vital Signs:
Patient Profile: 14 Years & 7 Months Old Female
Height: 67 inches (131.83 cm)
Weight: 135.5 pounds
BMI: 21.30
BSA: 1.72
Temp: 97.6 degrees F temporal
Pulse rate: 68 / minute
Pulse rhythm: regular
BP sitting: 106 / 68 (left arm)
Cuff size: regular
Vitals Entered By: Brianne Watson MA (January 29, 2014 3:44 PM)
Physical Exam
General:
Well appearing adolescent,no acute distress
Genitalia:
normal female; tiny papule at posterior right labia- not tender or erythematous- ?cystic
Musculoskeletal:
left lateral chest wall nontender
Impression & Recommendations:
Problem # 1: SKIN LESION (ICD-709.9)
possibly ingrown hair or small cyst- reassurance given; call if grows or becomes bothersome
