I am coming up with 99213. Problem low data min Risk Low . Using Z30.09 for dx.
CHIEF COMPLAINT
The Chief Complaint is: Pt id x2, consult removal/ replace nexplanon
HISTORY OF PRESENT ILLNESS
Pt here with her mom to discuss nexplanon issues
Has had it x 2 years, started with sx of depression shortly after insertion, is now on anti depressive
Having near constant light bleeding and worsening acne
is sexually active., feels not at risk for STD's
Has used oc's before but cant remember them
after discussion of possible side effects of Progesterone methods she wants to avoid them
We discussed Nuvaring,
she will rto for Nexplanon removal & Nuvaring Rx
Pt here with her mom to discuss nexplanon issues
Has had it x 2 years, started with sx of depression shortly after insertion, is now on anti depressive
Having near constant light bleeding and worsening acne
is sexually active., feels not at risk for STD's
Has used oc's before but cant remember them
after discussion of possible side effects of Progesterone methods she wants to avoid them
We discussed Nuvaring,
she will rto for Nexplanon removal & Nuvaring Rx
DISCUSSED
Family Planning methods, including LARCs (Nexplanon, Mirena, Paragard, and Skyla), Depo-Provera, combination oral contraceptive pills, progestin-only oral contraceptive pills, condoms, fertility awareness-based methods, and abstinence were discussed. The effectiveness, risks, benefits, and side effects of all methods were reviewed with the patient. The patient was given the opportunity to ask any questions about the discussed methods,
PLAN
rto for Nexplanon removal
CHIEF COMPLAINT
The Chief Complaint is: Pt id x2, consult removal/ replace nexplanon
HISTORY OF PRESENT ILLNESS
Pt here with her mom to discuss nexplanon issues
Has had it x 2 years, started with sx of depression shortly after insertion, is now on anti depressive
Having near constant light bleeding and worsening acne
is sexually active., feels not at risk for STD's
Has used oc's before but cant remember them
after discussion of possible side effects of Progesterone methods she wants to avoid them
We discussed Nuvaring,
she will rto for Nexplanon removal & Nuvaring Rx
Pt here with her mom to discuss nexplanon issues
Has had it x 2 years, started with sx of depression shortly after insertion, is now on anti depressive
Having near constant light bleeding and worsening acne
is sexually active., feels not at risk for STD's
Has used oc's before but cant remember them
after discussion of possible side effects of Progesterone methods she wants to avoid them
We discussed Nuvaring,
she will rto for Nexplanon removal & Nuvaring Rx
DISCUSSED
Family Planning methods, including LARCs (Nexplanon, Mirena, Paragard, and Skyla), Depo-Provera, combination oral contraceptive pills, progestin-only oral contraceptive pills, condoms, fertility awareness-based methods, and abstinence were discussed. The effectiveness, risks, benefits, and side effects of all methods were reviewed with the patient. The patient was given the opportunity to ask any questions about the discussed methods,
PLAN
rto for Nexplanon removal