jnieto625
Networker
I have a patient that came in for a PE. The CC states:
XXXX is a 20 year old female. This is her first visit to the office. She does not have a prior PCP. She is here for an annual exam.
A Health risk profile is done along with a comprehensive ROS and PMH/FMH/SH (All part of the PE). ROS does say irregular menstrual cycle (Often doesn't have for 3 months) and positive for fungal infection (left toe nails x 1yr) (everything else was negative) (A separate extensive HPI is NOT documented for either of these issues)
Provider does an exam - nothing listed under GENITOURINARY for the exam but does document onychomycosis of great toes(s) and toe(s); left
Provider then documents following plan (In addition to plan for annual physical):
Secondary amenorrhea Could be because of her low weight (athletes triad). Recommended adequate calorie intake and monitoring. We'll start with basic labs to help assess. Just finished her cycle so no hcg ordered.
Orders:
82670 Estradiol
84144 Progesterone
83001 FSH
83002 LH
84146 Prolactin
84443 Thyroid stimulating hormone (TSH)
Toe onychomycosis Start oral therapy after labs confirm normal LFTs - monthly lfts until condition is resolved
Orders:
80076 Hepatic function panel
I am questioning whether or not I have enough to bill a separate office visit. I keep going back and forth because she didn't come in presenting these problems and in my opinion there is not a significant HPI taken on them but the duration and timing is listed under the ROS. Would that be enough for a PF hx and straight forward decision making?
XXXX is a 20 year old female. This is her first visit to the office. She does not have a prior PCP. She is here for an annual exam.
A Health risk profile is done along with a comprehensive ROS and PMH/FMH/SH (All part of the PE). ROS does say irregular menstrual cycle (Often doesn't have for 3 months) and positive for fungal infection (left toe nails x 1yr) (everything else was negative) (A separate extensive HPI is NOT documented for either of these issues)
Provider does an exam - nothing listed under GENITOURINARY for the exam but does document onychomycosis of great toes(s) and toe(s); left
Provider then documents following plan (In addition to plan for annual physical):
Secondary amenorrhea Could be because of her low weight (athletes triad). Recommended adequate calorie intake and monitoring. We'll start with basic labs to help assess. Just finished her cycle so no hcg ordered.
Orders:
82670 Estradiol
84144 Progesterone
83001 FSH
83002 LH
84146 Prolactin
84443 Thyroid stimulating hormone (TSH)
Toe onychomycosis Start oral therapy after labs confirm normal LFTs - monthly lfts until condition is resolved
Orders:
80076 Hepatic function panel
I am questioning whether or not I have enough to bill a separate office visit. I keep going back and forth because she didn't come in presenting these problems and in my opinion there is not a significant HPI taken on them but the duration and timing is listed under the ROS. Would that be enough for a PF hx and straight forward decision making?