Greenpiper
Contributor
We are having a difference of opinion between coders and billers,
Coder coded as 99397.GY
No HPI
Missing updated written screening schedule 5-10yrs
Visit qualified as preventive and preventive 99397 is not covered by Medicare
Biller wants code changed to 99214 as provider refilled RX looked at previously ordered labs for DMII
Anyone have an idea of correct coding?
Thank you
CC: Medicare Wellness Visit.
History of Present Illness:
Patient here for Medicare exam. We did review Medicare form. All questions were answered. He is up-to-date on vaccinations. He will get shingles vaccination at Safeway. Did review prior specialty notes. Does see a cardiologist for aortic valve replacement in the past. Does see a dermatologist for multiple skin issues. He lives here with his wife during the summer. He has been doing well with his diabetes. He is very compliant with medications. Did review and fill out POLST form.
Date: This is the first Annual Medicare Exam this year. (08/08/2018 1:41:17 PM)
Hearing
Assessed whisper test hearing impaired
Falls Assessment
Ambulation:Normal
Get Up and Go:Good <15 seconds
Patient reports no falls within the past year.
Patient reports no balance problems.
Strength and Dexterity
Fine motor: Able to pick up pen
Proximal arm mobility: Able to touch back of head with both hands
Strength and tone: normal
Fall Risk: Low
Patient is independent with bathing.
Patient is independent with dressing.
Patient is independent with toileting.
Patient is independent with feeding.
Instrumental Activities of Daily Living
Are you independent with the following activities?
Patient is independent with using the telephone.
Patient is independent with shopping.
Patient is independent with meal preparation.
Patient is independent with light housework.
Patient is independent with doing personal laundry.
Patient is independent with arranging transportation.
Patient is independent with taking medications correctly.
Patient is independent with managing finances.
Social Support
Emergency contact listed in registration? Yes
Nutrition
Weight status: stable
Weight change is -4 lbs.
BMI 29.63 BMI Class: overweight
Nutrition Screening
Screening answered by: patient
Patient has not lost or gained 10 or more pounds without wanting to in the last 6 months.
Patient has no trouble swallowing or chewing food.
Patient eats 2 or more meals per day.
Patient's appetite is good.
Food does taste good to patient.
Patient does not omit any food groups from diet.
Depression
Patient does not feel depressed.
Patient has not been treated for depression in the past.
Geriatric Depression Screen
Patient basically satisfied with life.
Patient does not often get bored.
Patient does not often feel helpless.
Patient prefers going out and doing new things, rather than staying home.
Patient does not feel worthless in current state.
Score: 0
Patient Health Questionnaire (PHQ-9)
1. Over the last 2 weeks, how often have you been bothered by any of the following problems?
a. Little interest or pleasure in doing things: not at all
b. Feeling down, depressed or hopeless: not at all
c. Trouble falling/staying asleep, sleeping too much: not at all
d. Feeling tired or having little energy: not at all
e. Poor appetite or overeating: not at all
f. Feeling bad about yourself or that you are a failure or have let yourself or your family down: not at all
g. Trouble concentrating on things, such as reading the newspaper or watching television: not at all
h. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual: not at all
i. Thoughts that you would be better off dead or of hurting yourself in some way: not at all
2. If you checked off any problem on the questionaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
not difficult at all
Raw score 0
Score <4 Minimal depression
CARDIOVASCULAR RISK ASSESSMENT
Criteria Results Points
Age: 72 Years Old 18
Diabetes status: Yes 3
HDL Cholesterol: 54 -1
Total Cholesterol: 168 -1
Systolic BP: 118 0
Smoking status: 0
LVH Status (EKG): 0
Total Points: 19
Patient's 5-year probability of a coronary event: 8%
Patient's 10-year probability of a coronary event: 16%
Average 10-year probability of a coronary event: 24%
Behavioral counseling for alcohol misuse
Vital Signs:
Patient Profile: 72 Years Old Male
Height: 71.25 inches
Weight: 214 pounds
BMI: 29.63
O2 Sat: 95 %
Temp: 97.4 degrees F temporal
Pulse rate: 56 / minute
Pulse rhythm: regular
BP Sitting: 118 / 68 (left arm)
Cuff size: regular
Physical Exam
General:
Obese
Lungs:
clear bilaterally to auscultation.
Heart:
1/6 systolic ejection murmur
Pulses:
Right radial pulse 2+
Extremities:
No pedal edema
Neurologic:
Grossly intact
Skin:
intact without lesions or rashes.
Psych:
alert and cooperative; normal mood and affect; normal attention span and concentration.
Diabetes Management Exam:
Foot Exam (with socks and/or shoes not present):
Pulses:
Right radial pulse 2+
Blood Pressure:
Today's BP: 118/68 mm Hg
Labwork:
Most Recent Lab Results:
LDL: 85.0 mg/dL 08/10/2019
HbA1c: : 7.7 % 08/10/2019
Past Medical History:
Reviewed history from 08/25/2015 and no changes required:
diabetes type two
hyperlipidemia
aortic valve replacement
benign essential hypertension
Social History:
Reviewed history from 08/25/2015 and no changes required:
Alcohol Use - yes
Drug Use - no
HIV/High Risk - no
Regular Exercise - yes
Smoking History:
Patient has never smoked.
Risk Factors:
Smoked Tobacco Use: Former smoker
Previous Tobacco Use: Signed On - 08/08/2018
Smoked Tobacco Use: Former smoker
Cigarettes: Yes -- 2 pack(s) per day, Year started: 1966
Year quit: 1980
Years Since Last Quit: 39 years, 7 months, 11 days
Smokeless Tobacco Use: Never
Drug use: no
HIV high-risk behavior: no
Previous Alcohol Use: Signed On - 08/25/2015
Alcohol use: yes
Exercise: yes
Impression & Recommendations:
Problem # 1: Diabetes mellitus, type II (ICD-250.00) (ICD10-E11.9)
Reviewed labs. A1c 7.7. Discussed shoring up diet and lifestyle. Will follow up with his doctor in Arizona.
His updated medication list for this problem includes:
Metformin Hcl 1000 Mg Oral Tablet (Metformin hcl) ..... 1 tab bid
Ramipril 2.5 Mg Oral Capsule (Ramipril) ..... 1 tab qd
Orders:
Annual Wellness Visit, Initial (AWV) (CPT-G0438)
Problem # 2: Hypertension, benign essential (ICD-401.1) (ICD10-I10)
Assessment: Unchanged
His updated medication list for this problem includes:
Metoprolol Succinate Er 25 Mg Oral Tablet Extended Release 24 Hour (Metoprolol succinate) ..... 1 tab qd
Ramipril 2.5 Mg Oral Capsule (Ramipril) ..... 1 tab qd
Orders:
Annual Wellness Visit, Initial (AWV) (CPT-G0438)
Problem # 3: Hyperlipidemia (ICD-272.4) (ICD10-E78.5)
Assessment: Unchanged
His updated medication list for this problem includes:
Niacin Er 1000 Mg Oral Tablet Extended Release (Niacin) ..... 1 tab qd
Crestor 20 Mg Oral Tablet (Rosuvastatin calcium) ..... 1 tab qd
Orders:
Annual Wellness Visit, Initial (AWV) (CPT-G0438)
Problem # 4: Disorder, aortic valve (ICD-424.1) (ICD10-I35.8)
Assessment: Unchanged
Currently anticoagulated. Stable.
Orders:
Annual Wellness Visit, Initial (AWV) (CPT-G0438)
Problem # 5: Eczema, atopic (ICD-691.8) (ICD10-L20.9)
Assessment: Unchanged
Refilled medication.
Orders:
Annual Wellness Visit, Initial (AWV) (CPT-G0438)
Medications Added to Medication List This Visit:
1) Ketoconazole 2 % External Cream (Ketoconazole) .... Apply twice daily
Medications:
KETOCONAZOLE 2 % EXTERNAL CREAM (KETOCONAZOLE) apply twice daily #30gm x 5
Active Medications:
CINAMON ()
MOVE FREE ()
FISH OIL ()
MULTIVITAMIN ()
ASA 81MG () 1 tab qd
METFORMIN HCL 1000 MG ORAL TABLET (METFORMIN HCL) 1 tab BID
WARFARIN SODIUM 5 MG ORAL TABLET (WARFARIN SODIUM) 1 tab qd
METOPROLOL SUCCINATE ER 25 MG ORAL TABLET EXTENDED RELEASE 24 HOUR (METOPROLOL SUCCINATE) 1 tab qd
NIACIN ER 1000 MG ORAL TABLET EXTENDED RELEASE (NIACIN) 1 tab qd
CRESTOR 20 MG ORAL TABLET (ROSUVASTATIN CALCIUM) 1 tab qd
RAMIPRIL 2.5 MG ORAL CAPSULE (RAMIPRIL) 1 tab qd
Current Allergies:
PENICILLIN (Moderate)
NEOSPORIN ORIGINAL (Moderate)
Vaccines Administered/Entered:
Vaccination Group: Pneumococcal PPSV23
Historical Source: Historical information - from patient
Comments :
Problems Added:
Diabetes mellitus, type II (ICD-250.00) (ICD10-E11.9)
Hypertension, benign essential (ICD-401.1) (ICD10-I10)
Hyperlipidemia (ICD-272.4) (ICD10-E78.5)
Disorder, aortic valve (ICD-424.1) (ICD10-I35.8)
Eczema, atopic (ICD-691.8) (ICD10-L20.9)
________________________________________________________________________
Coder coded as 99397.GY
No HPI
Missing updated written screening schedule 5-10yrs
Visit qualified as preventive and preventive 99397 is not covered by Medicare
Biller wants code changed to 99214 as provider refilled RX looked at previously ordered labs for DMII
Anyone have an idea of correct coding?
Thank you
CC: Medicare Wellness Visit.
History of Present Illness:
Patient here for Medicare exam. We did review Medicare form. All questions were answered. He is up-to-date on vaccinations. He will get shingles vaccination at Safeway. Did review prior specialty notes. Does see a cardiologist for aortic valve replacement in the past. Does see a dermatologist for multiple skin issues. He lives here with his wife during the summer. He has been doing well with his diabetes. He is very compliant with medications. Did review and fill out POLST form.
Date: This is the first Annual Medicare Exam this year. (08/08/2018 1:41:17 PM)
Hearing
Assessed whisper test hearing impaired
Falls Assessment
Ambulation:Normal
Get Up and Go:Good <15 seconds
Patient reports no falls within the past year.
Patient reports no balance problems.
Strength and Dexterity
Fine motor: Able to pick up pen
Proximal arm mobility: Able to touch back of head with both hands
Strength and tone: normal
Fall Risk: Low
Patient is independent with bathing.
Patient is independent with dressing.
Patient is independent with toileting.
Patient is independent with feeding.
Instrumental Activities of Daily Living
Are you independent with the following activities?
Patient is independent with using the telephone.
Patient is independent with shopping.
Patient is independent with meal preparation.
Patient is independent with light housework.
Patient is independent with doing personal laundry.
Patient is independent with arranging transportation.
Patient is independent with taking medications correctly.
Patient is independent with managing finances.
Social Support
Emergency contact listed in registration? Yes
Nutrition
Weight status: stable
Weight change is -4 lbs.
BMI 29.63 BMI Class: overweight
Nutrition Screening
Screening answered by: patient
Patient has not lost or gained 10 or more pounds without wanting to in the last 6 months.
Patient has no trouble swallowing or chewing food.
Patient eats 2 or more meals per day.
Patient's appetite is good.
Food does taste good to patient.
Patient does not omit any food groups from diet.
Depression
Patient does not feel depressed.
Patient has not been treated for depression in the past.
Geriatric Depression Screen
Patient basically satisfied with life.
Patient does not often get bored.
Patient does not often feel helpless.
Patient prefers going out and doing new things, rather than staying home.
Patient does not feel worthless in current state.
Score: 0
Patient Health Questionnaire (PHQ-9)
1. Over the last 2 weeks, how often have you been bothered by any of the following problems?
a. Little interest or pleasure in doing things: not at all
b. Feeling down, depressed or hopeless: not at all
c. Trouble falling/staying asleep, sleeping too much: not at all
d. Feeling tired or having little energy: not at all
e. Poor appetite or overeating: not at all
f. Feeling bad about yourself or that you are a failure or have let yourself or your family down: not at all
g. Trouble concentrating on things, such as reading the newspaper or watching television: not at all
h. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual: not at all
i. Thoughts that you would be better off dead or of hurting yourself in some way: not at all
2. If you checked off any problem on the questionaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
not difficult at all
Raw score 0
Score <4 Minimal depression
CARDIOVASCULAR RISK ASSESSMENT
Criteria Results Points
Age: 72 Years Old 18
Diabetes status: Yes 3
HDL Cholesterol: 54 -1
Total Cholesterol: 168 -1
Systolic BP: 118 0
Smoking status: 0
LVH Status (EKG): 0
Total Points: 19
Patient's 5-year probability of a coronary event: 8%
Patient's 10-year probability of a coronary event: 16%
Average 10-year probability of a coronary event: 24%
Behavioral counseling for alcohol misuse
Vital Signs:
Patient Profile: 72 Years Old Male
Height: 71.25 inches
Weight: 214 pounds
BMI: 29.63
O2 Sat: 95 %
Temp: 97.4 degrees F temporal
Pulse rate: 56 / minute
Pulse rhythm: regular
BP Sitting: 118 / 68 (left arm)
Cuff size: regular
Physical Exam
General:
Obese
Lungs:
clear bilaterally to auscultation.
Heart:
1/6 systolic ejection murmur
Pulses:
Right radial pulse 2+
Extremities:
No pedal edema
Neurologic:
Grossly intact
Skin:
intact without lesions or rashes.
Psych:
alert and cooperative; normal mood and affect; normal attention span and concentration.
Diabetes Management Exam:
Foot Exam (with socks and/or shoes not present):
Pulses:
Right radial pulse 2+
Blood Pressure:
Today's BP: 118/68 mm Hg
Labwork:
Most Recent Lab Results:
LDL: 85.0 mg/dL 08/10/2019
HbA1c: : 7.7 % 08/10/2019
Past Medical History:
Reviewed history from 08/25/2015 and no changes required:
diabetes type two
hyperlipidemia
aortic valve replacement
benign essential hypertension
Social History:
Reviewed history from 08/25/2015 and no changes required:
Alcohol Use - yes
Drug Use - no
HIV/High Risk - no
Regular Exercise - yes
Smoking History:
Patient has never smoked.
Risk Factors:
Smoked Tobacco Use: Former smoker
Previous Tobacco Use: Signed On - 08/08/2018
Smoked Tobacco Use: Former smoker
Cigarettes: Yes -- 2 pack(s) per day, Year started: 1966
Year quit: 1980
Years Since Last Quit: 39 years, 7 months, 11 days
Smokeless Tobacco Use: Never
Drug use: no
HIV high-risk behavior: no
Previous Alcohol Use: Signed On - 08/25/2015
Alcohol use: yes
Exercise: yes
Impression & Recommendations:
Problem # 1: Diabetes mellitus, type II (ICD-250.00) (ICD10-E11.9)
Reviewed labs. A1c 7.7. Discussed shoring up diet and lifestyle. Will follow up with his doctor in Arizona.
His updated medication list for this problem includes:
Metformin Hcl 1000 Mg Oral Tablet (Metformin hcl) ..... 1 tab bid
Ramipril 2.5 Mg Oral Capsule (Ramipril) ..... 1 tab qd
Orders:
Annual Wellness Visit, Initial (AWV) (CPT-G0438)
Problem # 2: Hypertension, benign essential (ICD-401.1) (ICD10-I10)
Assessment: Unchanged
His updated medication list for this problem includes:
Metoprolol Succinate Er 25 Mg Oral Tablet Extended Release 24 Hour (Metoprolol succinate) ..... 1 tab qd
Ramipril 2.5 Mg Oral Capsule (Ramipril) ..... 1 tab qd
Orders:
Annual Wellness Visit, Initial (AWV) (CPT-G0438)
Problem # 3: Hyperlipidemia (ICD-272.4) (ICD10-E78.5)
Assessment: Unchanged
His updated medication list for this problem includes:
Niacin Er 1000 Mg Oral Tablet Extended Release (Niacin) ..... 1 tab qd
Crestor 20 Mg Oral Tablet (Rosuvastatin calcium) ..... 1 tab qd
Orders:
Annual Wellness Visit, Initial (AWV) (CPT-G0438)
Problem # 4: Disorder, aortic valve (ICD-424.1) (ICD10-I35.8)
Assessment: Unchanged
Currently anticoagulated. Stable.
Orders:
Annual Wellness Visit, Initial (AWV) (CPT-G0438)
Problem # 5: Eczema, atopic (ICD-691.8) (ICD10-L20.9)
Assessment: Unchanged
Refilled medication.
Orders:
Annual Wellness Visit, Initial (AWV) (CPT-G0438)
Medications Added to Medication List This Visit:
1) Ketoconazole 2 % External Cream (Ketoconazole) .... Apply twice daily
Medications:
KETOCONAZOLE 2 % EXTERNAL CREAM (KETOCONAZOLE) apply twice daily #30gm x 5
Active Medications:
CINAMON ()
MOVE FREE ()
FISH OIL ()
MULTIVITAMIN ()
ASA 81MG () 1 tab qd
METFORMIN HCL 1000 MG ORAL TABLET (METFORMIN HCL) 1 tab BID
WARFARIN SODIUM 5 MG ORAL TABLET (WARFARIN SODIUM) 1 tab qd
METOPROLOL SUCCINATE ER 25 MG ORAL TABLET EXTENDED RELEASE 24 HOUR (METOPROLOL SUCCINATE) 1 tab qd
NIACIN ER 1000 MG ORAL TABLET EXTENDED RELEASE (NIACIN) 1 tab qd
CRESTOR 20 MG ORAL TABLET (ROSUVASTATIN CALCIUM) 1 tab qd
RAMIPRIL 2.5 MG ORAL CAPSULE (RAMIPRIL) 1 tab qd
Current Allergies:
PENICILLIN (Moderate)
NEOSPORIN ORIGINAL (Moderate)
Vaccines Administered/Entered:
Vaccination Group: Pneumococcal PPSV23
Historical Source: Historical information - from patient
Comments :
Problems Added:
Diabetes mellitus, type II (ICD-250.00) (ICD10-E11.9)
Hypertension, benign essential (ICD-401.1) (ICD10-I10)
Hyperlipidemia (ICD-272.4) (ICD10-E78.5)
Disorder, aortic valve (ICD-424.1) (ICD10-I35.8)
Eczema, atopic (ICD-691.8) (ICD10-L20.9)
________________________________________________________________________