rcbaker
Networker
please help me: the patient is an 18 month old girl initially seen in this clinic on december 1st. there were long standing concerns about her overall development. she was born at 34 weeks. her neonatal course was complicated by gastroischisis. here initial hospitalization lasted approximately 1 month.
she has shown significant deficits in all of her gross motor skills, and there were concerns about dysconjugate gaze. at the time of her initial examination, microcephaly was also noted. she was alert and smiled briefly. she had good head control. she was unable to maintain a sitting position. she had a decrease in muscle mass and increase in tone diffusely. this was more noticeable in her lower than her upper extremities. she was hyperreflexic. she had crossed adductor response and extensor plantar response as well.
since then, the patient has made improvement in her language and motor skills. currently, she says several words that are easily understandable at home. she smiles, she is friendly, and she is interactive. she continues to have significant gross motor difficulties. she now sits much better than she did previously, and she will pull to stand. she is engaged in a therapy program.
the patient had an mri performed about a week ago. it was available for review. it showed significant white matter loss both in the frontal and posterior head regions. there were some areas of cystic encephalomalacia.
the results of the mri were explained to the patient's parents. the patient's history and her neurological examination and her mri are consistent with non progressive process that probably is a consequence of her preterm birth and acute illness at that time. her overall language and social skills today are in the normal range, particualary when adjusted for gestational age. she continues to have significant motor deficits. plans were made for the patient to be seen in followup in the neurolog clinic.
doctor selection e/m 99214. How can i audit this?
she has shown significant deficits in all of her gross motor skills, and there were concerns about dysconjugate gaze. at the time of her initial examination, microcephaly was also noted. she was alert and smiled briefly. she had good head control. she was unable to maintain a sitting position. she had a decrease in muscle mass and increase in tone diffusely. this was more noticeable in her lower than her upper extremities. she was hyperreflexic. she had crossed adductor response and extensor plantar response as well.
since then, the patient has made improvement in her language and motor skills. currently, she says several words that are easily understandable at home. she smiles, she is friendly, and she is interactive. she continues to have significant gross motor difficulties. she now sits much better than she did previously, and she will pull to stand. she is engaged in a therapy program.
the patient had an mri performed about a week ago. it was available for review. it showed significant white matter loss both in the frontal and posterior head regions. there were some areas of cystic encephalomalacia.
the results of the mri were explained to the patient's parents. the patient's history and her neurological examination and her mri are consistent with non progressive process that probably is a consequence of her preterm birth and acute illness at that time. her overall language and social skills today are in the normal range, particualary when adjusted for gestational age. she continues to have significant motor deficits. plans were made for the patient to be seen in followup in the neurolog clinic.
doctor selection e/m 99214. How can i audit this?