We have a neurologist who says all his new/established patients are usually a level 5. Provider is not using TIME to determine his level of service, its all based on MDM. There has been discussion that his documentation is meeting a level 4 and not a five.
Can someone review this example, would like any feedback.
New patient:
CC: Migraine headaches
HPI: This is a 66-year-old right-handed originally Hispanic woman was seen for the first time. She has been suffering migraine headaches since age of 15 and generally she may get 6 headaches at least 2-3 times per week. Her headache is mainly unilateral pounding with photophobia phonophobia and sometimes nausea. She also sometimes get visual aura before the headaches. She was previously getting Botox injections till August of last year when it was stopped due to some side effects including pain and hair loss at the site of injections. She is currently taking Imitrex 100 mg as needed for severe headaches. She may take Tylenol 500 mg when the headaches comes but on top of it she also takes naproxen for her bad right hip which she had surgery on it in the past. If she can do her exercises her sleep is well otherwise not and with the fact that she has some hip pain she was not able to do good exercises recently. She admits that she has some anxiety and sometimes suddenly she started to have some heart palpitation and hand sweating and get anxious. She is taking vitamin D3 as well. There is a positive family history and her sister also suffers from migraine headaches. She had a CT scan of the head in 2015 which did not show any acute processes.
Physical Examination:
GEN: NAD
Cardiac: Regular rate and rhythm.
Pulm: Clear to auscultation.
Neurological examination:
Higher function test: Patient is alert and oriented x 3 speech is fluent and comprehensive. Memory and cognitive function test is intact.
Cranial Nerve Exam: Pupils are round and reactive bilaterally. Extraocular movements are full. Tongue protrudes in the midline and moves well from side-to-side. Hearing is grossly intact bilaterally. Shoulder shrug is symmetrical and normal. Facial sensation and strength is normal bilaterally. Rest of the cranial nerve exam is intact.
Motor exam: Gait is antalgic due to right hip pain. Tandem walking is not possible due to hip issue. Patient has a strength of 5 out of 5 throughout. Bulk and tone appears to be intact. Finger-to-nose test is intact bilaterally. Heel-to-shin test is intact bilaterally. Rapid alternating movement is intact throughout.
Sensory exam: Light touch and vibration is intact throughout. Pinprick and proprioception is intact throughout. Romberg sign is absent.
Reflexes: 2+ out of 5 throughout. Plantars are bilaterally withdrawal.
Impression and Plan: This is a 66-year-old right-handed originally Hispanic woman who comes with chronic migraine headaches. I talked to her regarding the prophylactic therapy considering the number of the headaches that she has monthly and with consideration of her anxiety I will give her a trial of Effexor 37.5 mg daily. She will add vitamin B2 400 mg to her vitamin D3 also to take melatonin 1 mg as needed for her sleep issues. For abortive therapy she will continue with Imitrex 100 mg only as needed for migraine attack and not to take more than 2 pills per 24 hours and 5/week. She will need to try to decrease the level of stress also to decrease taking Tylenol for her headaches. Follow-up in 10 weeks, sooner if needed.
I discussed with the patient differential diagnosis, possible etiology of symptoms and treatment plan. Patient's lab/imaging reviewed.
Can someone review this example, would like any feedback.
New patient:
CC: Migraine headaches
HPI: This is a 66-year-old right-handed originally Hispanic woman was seen for the first time. She has been suffering migraine headaches since age of 15 and generally she may get 6 headaches at least 2-3 times per week. Her headache is mainly unilateral pounding with photophobia phonophobia and sometimes nausea. She also sometimes get visual aura before the headaches. She was previously getting Botox injections till August of last year when it was stopped due to some side effects including pain and hair loss at the site of injections. She is currently taking Imitrex 100 mg as needed for severe headaches. She may take Tylenol 500 mg when the headaches comes but on top of it she also takes naproxen for her bad right hip which she had surgery on it in the past. If she can do her exercises her sleep is well otherwise not and with the fact that she has some hip pain she was not able to do good exercises recently. She admits that she has some anxiety and sometimes suddenly she started to have some heart palpitation and hand sweating and get anxious. She is taking vitamin D3 as well. There is a positive family history and her sister also suffers from migraine headaches. She had a CT scan of the head in 2015 which did not show any acute processes.
Physical Examination:
GEN: NAD
Cardiac: Regular rate and rhythm.
Pulm: Clear to auscultation.
Neurological examination:
Higher function test: Patient is alert and oriented x 3 speech is fluent and comprehensive. Memory and cognitive function test is intact.
Cranial Nerve Exam: Pupils are round and reactive bilaterally. Extraocular movements are full. Tongue protrudes in the midline and moves well from side-to-side. Hearing is grossly intact bilaterally. Shoulder shrug is symmetrical and normal. Facial sensation and strength is normal bilaterally. Rest of the cranial nerve exam is intact.
Motor exam: Gait is antalgic due to right hip pain. Tandem walking is not possible due to hip issue. Patient has a strength of 5 out of 5 throughout. Bulk and tone appears to be intact. Finger-to-nose test is intact bilaterally. Heel-to-shin test is intact bilaterally. Rapid alternating movement is intact throughout.
Sensory exam: Light touch and vibration is intact throughout. Pinprick and proprioception is intact throughout. Romberg sign is absent.
Reflexes: 2+ out of 5 throughout. Plantars are bilaterally withdrawal.
Impression and Plan: This is a 66-year-old right-handed originally Hispanic woman who comes with chronic migraine headaches. I talked to her regarding the prophylactic therapy considering the number of the headaches that she has monthly and with consideration of her anxiety I will give her a trial of Effexor 37.5 mg daily. She will add vitamin B2 400 mg to her vitamin D3 also to take melatonin 1 mg as needed for her sleep issues. For abortive therapy she will continue with Imitrex 100 mg only as needed for migraine attack and not to take more than 2 pills per 24 hours and 5/week. She will need to try to decrease the level of stress also to decrease taking Tylenol for her headaches. Follow-up in 10 weeks, sooner if needed.
I discussed with the patient differential diagnosis, possible etiology of symptoms and treatment plan. Patient's lab/imaging reviewed.