I don't know where to go from here. I just don't what she is doing is correct.
This is what the email said: "as long as the AWV documentation guidelines are met then they should be coded, however if the AWV are not supported but an E&M is supported then those should be billed. The service that should be billed is based on the documentation in the medical record" She had it changed to 99213.
Notes:
CHIEF COMPLAINT: yearly physical HPI: comes in today for annual physical. Follows with Podiarty, dentist, eye doctor , ENT and Neurology. Has not seen Hematology or Pulmonology since admission for PE and pneumonia. No recent issues with cough/SOB. At usual activity level .
REVIEW OF SYSTEM: CONSTITUTIONAL: Patient denies fevers, chills, sweats. No fatigue. weight changes -stable. EYES: Patient denies any visual symptoms. EARS, NOSE, And THROAT: + difficulties with hearing-right hearing aide. No symptoms of rhinitis Or sore throat. CARDIOVASCULAR: Patient denies chest pains, palpitations RESPIRATORY: No dyspnea On exertion, no wheezing Or cough. Uses CPAP. NO respiratory issues-continues with nebulizer treatments bid. GI: No nausea, vomiting, diarrhea, constipation, abdominal pain, no change in bowel pattern. No blood noted.No heartburn. GU: No urinary hesitancy Or dribbling. No nocturia Or urinary frequency. MUSCULOSKELETAL: No myalgias Or arthralgias. NEUROLOGIC: No chronic headaches. No dizziness Patient denies numbness, tingling Or weakness. PSYCHIATRIC: Patient denies problems with mood disturbance. No problems with anxiety/depression. No outburst. Talks to "unseen" person at various times of the day-able to be redirected. ENDOCRINE: No excessive urination Or excessive thirst. DERMATOLOGIC: Patient denies any rashes Or skin changes. ALLERGIES: Doxycycline:Unspecified HISTORY: Past Medical History: Down's Syndrome HOH- right PE- 8/2019- No DVT Social History: Never Smoker
EXAM: General: Well appearing, well nourished, in no distress. Oriented x 2, normal mood And affect . Ambulating without difficulty. Skin: Good turgor, no rash, unusual bruising Or prominent lesions HEENT: Head: Normocephalic Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL Ears: EACs -dry cerumin. TMs Nose: No external lesions, mucosa non-inflamed, septum And turbinates normal Mouth: Mucous membranes moist, no mucosal lesions. Teeth/ Gums: No obvious caries Or periodontal disease. Pharynx: Mucosa non - inflamed, no tonsillar hypertrophy Or exudate Neck: Supple, without lesions Or adenopathy, thyroid non-enlarged And non-tender Heart: No cardiomegaly Or thrills; regular rate And rhythm, no murmur , No bruit. Lungs: Clear to auscultation . No wheeze/rhonchi Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, Or hernia Back: Spine normal without deformity Or tenderness Extremities: No edema. peripheral pulses intact. No abnormal weakness. Musculoskeletal: Normal gait And station. Normal ROM of extremities. Neurologic: CN 2 - 12 normal- limited assessement Psychiatric: Oriented X 2 normal mood and affect.
DIAGNOSTIC ASSESSMENT: Z00.01: ENCOUNTER FOR GENERAL ADULT MEDICAL EXAM W ABNORMAL FINDINGS...Z00.01 Q90.9: DOWN SYNDROME, UNSPECIFIED...Q90.9 J45.20: MILD INTERMITTENT ASTHMA, UNCOMPLIC...J45.20 G47.33: OBSTRUCTIVE SLEEP APNEA (ADULT) (PE...G47.33 E03.9: HYPOTHYROIDISM, UNSPECIFIED...E03.9...E03.9 M81.0: AGE-RELATED OSTEOPOROSIS W/O CURREN...M81.0 I26.99: OTHER PULMONARY EMBOLISM WITHOUT AC...I26.99 TREATMENT PLAN: Will stop albuterol treatments and continue with Budesinide Needs repeat chest xray s/p pneumonia eailer this month Needs f/u with Hematology and Pulmonology for new Dx PE Complete lab work MEDICATION PRESCRIBED/RECONCILED: Patient's medication has been reconciled. quetiapine ER 50 mg tablet,extended release 24 hr:1 tablet by mouth daily; Dispense:30; (6/25/2019) Depakote 500 mg tablet,delayed release:1 tablet by mouth twice a day; Dispense:60; (2/21/2019) Nexium 40 mg capsule,delayed release:1 capsule by mouth daily; Dispense:30; (2/21/2019) ferrous sulfate 325 mg (65 mg iron) tablet:1 tablet by mouth daily; Dispense:30; (2/21/2019) metronidazole 0.75 % topical cream:1 application apply on the skin daily; Dispense:1; (2/21/2019) Oyster Shell Calcium 500 mg calcium (1,250 mg) tablet:1 tablet by mouth daily; Dispense:30; (2/21/2019) Prolia 60 mg/mL subcutaneous syringe:1 mL inject below the skin ; Dispense:1; (2/21/2019) levothyroxine 112 mcg tablet:1 tablet by mouth in the morning; Dispense:90; (6/25/2019) montelukast 10 mg tablet:1 tablet by mouth daily; Dispense:30; (2/22/2019) Reguloid oral powder:1 gm by mouth daily; Dispense:369; (3/4/2019) budesonide 0.5 mg/2 mL suspension for nebulization:1 mL inhale twice a day; Dispense:60; (5/29/2019) quetiapine 300 mg tablet:1 tablet by mouth Select Frequency; Dispense:; (3/29/2019) levothyroxine 112 mcg tablet:1 tablet by mouth in the morning; Dispense:90; (3/29/2019) budesonide 0.5 mg/2 mL suspension for nebulization:1 mL inhale twice a day; Dispense:60; (5/21/2019) ferrous sulfate 325 mg (65 mg iron) tablet:1 tablet by mouth daily; Dispense:30; (7/11/2019) Calcium 500 + D 500 mg(1,250 mg)-400 unit chewable tablet:1 tablet by mouth daily; Dispense:30; (7/15/2019) Eliquis 5 mg tablet:1 tablet by mouth twice a day; Dispense:60; (9/5/2019) sertraline 50 mg tablet:1 tablet by mouth daily; Dispense:30; (9/5/2019) ciclopirox 8 % topical solution:1 mL apply on the skin nightly; Dispense:1; (9/5/2019) LAB RESULT AND TESTS ORDERED: The following lab tests are ordered: X-RAY - A-I-0068:CHEST PA & LATERAL REGULAR - 004259:TSH 005009:CBC With Differential/Platelet 010322
rostate-Specific Ag, Serum 096206:Varicella-Zoster V Ab, IgG 303756:Lipid Panel 322000:Comp. Metabolic Panel (14)REFERRAL: BILLING INFORMATION: 99396 x 1.00 unit(s) - Preventive visit, established, age 40-64 SIGNED OFF SIGNATURE: