wonder1963
Networker
Example: These are the drs notes in EHR....
Chief Complaint: Wants to know why her Vit D 3 was not refilled, Her inhalers
are also out of refills, Concerned abvout not hearing from Referral, forRt. Knee
HISTORY OF PRESENT ILLNESS:
xxxxxxxxxxx is a 67 year-old FEMALE who presents to the clinic for f/u
and is requesting medication refills.No new
complaints.
REVIEW OF SYSTEMS
Constitutional:
Denies: fever, weight loss, chills, or swollen gland
Cardiovascular:
Denies: chest pain, dyspnea, orthopnea, palpitations, or edema
Respiratory:
Denies: shortness of breath, cough, or wheezing
Gastrointestinal:
Denies: abdominal pain, nausea, vomiting, diarrhea, or constipation
Musculoskeletal:
Complains Of: back pain, knee pain.
PAST MEDICAL HISTORY:
Active Problems:
htn (Last update on xxxxxx
hyperlipidemia (Last update on xxxxxxxx
Wheezing (Last update on xxxxxxx
Depression (Last update on xxxxxxxxx
Anxiety-Unspec. (Last update on xxxxxxxxxxxx
Osteoarthritis-Unspec (Last update on xxxxxxxxx
Tobacco Dependence (Last update on xxxxxxxxxxxxx
COPD NOS (Last update on xxxxxxxxxxx
Peripheral Vascular Disease, Unspecified xxxxxxxxx
Lumbosacral Spondylosis Without Myelopathy (Last update on xxxxxxxxx
Pain In Joint, Lower Leg (Last update on xxxxxxxxxxxxx
Allergies:
Patient has answered NKA
Medications:
Medication Reconciliation done.
FAMILY HISTORY:
########################################################################
NATURAL FATHERxxxxx DECEASED
Deceased: 60 and older Cause of death: Heart
NATURAL MOTHER xxxxxxx] DECEASED
Cause of death: Heart Attact
SOCIAL HISTORY:
Substance Abuse:
Alcohol: None FoundLast ALCOHOL/DRUG HF: CAGE 0/4 - xxxxxxx
Tobacco: CURRENT SMOKER, EVERY DAY - xxxxxxx
PHYSICAL EXAM:
Vital Signs: WT:191.00 (86.71 kg), HT:67.00 (170.18 cm), BP:112/68, PU:63,
TMP:97.60 (36.4 C), O2:92[ ], RS:20
General Exam:
Well-developed, well nourished, with no signs of acute distress.
HEENT:
Normocephalic, non-traumatic. TM's are normal bilaterally. Pupils are
equal
and round, and react to light. Extraocular movements are intact.
Fundiscopic exam shows normal disc and vasculature. There is no
nasal congestion. The mouth shows moist mucous membranes.
Good dentition. The oropharynx is clear.
Neck:
Supple. Non-tender. There is no lymphadenopathy.
Lungs:
Clear to auscultation bilaterally.
Heart/CV Exam:
Regular rate and rhythm without murmurs or rubs.
Abdomen Exam:
Soft. Non-tender. Bowel sounds are positive.
There is no hepatosplenomegaly.
Extremities:
Full range of motion. No joint tenderness. Pulses 2+.
There is no cyanosis or edema.
ASSESSMENT:
1) HTN [P]
2) Hyperlipidemia
3) Depression
4) COPD NOS
5) Lumbosacral Spondylosis Without Myelopathy
6) Anxiety-Unspec.
7) Issue Of Repeat Prescriptions
PLAN:
1) Renew and continue all chronic medications as directed.
2) Check on referral status.
Today's Orders:
Renew ALBUTEROL HFA 90MCG/SPRAY INHL,ORAL 90MCG/ACTUAT INHALE TWO (2) PUFFS
BY MOUTH EVERY 4 HOURS AS NEEDED FOR BREATHING Quantity: 6.7 Days: 30 Refills:
6 *Chronic Med: YES Dispense as Written: NO Indication: Wheezing
Renew ASPIRIN TAB,EC 81MG TAKE ONE (1) TABLET BY MOUTH DAILY ATTACK TO
REDUCE RISK OF STROKE OR HEART ATTACK Quantity: 30 Days: 30 Refills: 6
*Chronic Med: YES
Renew BACLOFEN TAB 10MG TAKE ONE (1) TABLET BY MOUTH FOUR TIMES A DAY AS
NEEDED FOR MUSCLE SPASMS Quantity: 120 Days: 30 Refills: 6 *Chronic Med: NO
Dispense as Written: NO Indication: Spasms
Renew buPROPion TAB,SA 150MG TAKE ONE (1) TABLET BY MOUTH DAILY FOR
DEPRESSION Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES
Renew CARVEDILOL TAB 12.5MG TAKE ONE (1) TABLET BY MOUTH TWICE A DAY FOR
HEART Quantity: 60 Days: 30 Refills: 6 *Chronic Med: YES
Renew CITALOPRAM TAB 40MG TAKE ONE (1) TABLET BY MOUTH DAILY FOR
DEPRESSION Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES
Renew FLUTICASONE/SALMETEROL 100MCG/50MCG DISKUS INHALE ONE (1) PUFF BY
MOUTH TWICE A DAY FOR ASTHMA Quantity: 60 Days: 30 Refills: 6 *Chronic Med:
YES Dispense as Written: NO Indication: COPD
Renew GABAPENTIN CAP,ORAL 300MG TAKE TWO (2) CAPSULES BY MOUTH 3 TIMES A
DAY DROWSINESS* FOR NERVE PAIN *MAY CAUSE DROWSINESS* Quantity: 180 Days: 30
Refills: 6 *Chronic Med: YES
Renew LOSARTAN TAB 100MG TAKE ONE (1) TABLET BY MOUTH DAILY FOR HIGH
BLOOD PRESSURE Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES
Renew MELOXICAM TAB 7.5MG TAKE ONE (1) TABLET BY MOUTH EVERY DAY FOR
PAIN AND INFLAMMATION Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES
Renew NORTRIPTYLINE CAP,ORAL 25MG TAKE ONE (1) CAPSULE BY MOUTH AT BEDTIME
FOR DEPRESSION Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES
Renew OMEPRAZOLE CAP,EC 20MG TAKE ONE (1) CAPSULE BY MOUTH EVERY MORNING
FOR STOMACH Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES
Renew SIMVASTATIN TAB 80MG TAKE ONE (1) TABLET BY MOUTH EVERY EVENING FOR
HIGH CHOLESTEROL Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES Dispense
as Written: NO Indication: hyperlipidemia
Follow-up: as directed.
/
Signed: xxxxxx
PROVIDER SELECTED 99212 AS the E/M code and as the diagnosis listed he
401.1 as primary then 272.4,311.,496.,721.3,300.00
The coder did not change anything .... is this correct ?
pt has medicare, so am I to only bill using the 401.1 dx.....?
Chief Complaint: Wants to know why her Vit D 3 was not refilled, Her inhalers
are also out of refills, Concerned abvout not hearing from Referral, forRt. Knee
HISTORY OF PRESENT ILLNESS:
xxxxxxxxxxx is a 67 year-old FEMALE who presents to the clinic for f/u
and is requesting medication refills.No new
complaints.
REVIEW OF SYSTEMS
Constitutional:
Denies: fever, weight loss, chills, or swollen gland
Cardiovascular:
Denies: chest pain, dyspnea, orthopnea, palpitations, or edema
Respiratory:
Denies: shortness of breath, cough, or wheezing
Gastrointestinal:
Denies: abdominal pain, nausea, vomiting, diarrhea, or constipation
Musculoskeletal:
Complains Of: back pain, knee pain.
PAST MEDICAL HISTORY:
Active Problems:
htn (Last update on xxxxxx
hyperlipidemia (Last update on xxxxxxxx
Wheezing (Last update on xxxxxxx
Depression (Last update on xxxxxxxxx
Anxiety-Unspec. (Last update on xxxxxxxxxxxx
Osteoarthritis-Unspec (Last update on xxxxxxxxx
Tobacco Dependence (Last update on xxxxxxxxxxxxx
COPD NOS (Last update on xxxxxxxxxxx
Peripheral Vascular Disease, Unspecified xxxxxxxxx
Lumbosacral Spondylosis Without Myelopathy (Last update on xxxxxxxxx
Pain In Joint, Lower Leg (Last update on xxxxxxxxxxxxx
Allergies:
Patient has answered NKA
Medications:
Medication Reconciliation done.
FAMILY HISTORY:
########################################################################
NATURAL FATHERxxxxx DECEASED
Deceased: 60 and older Cause of death: Heart
NATURAL MOTHER xxxxxxx] DECEASED
Cause of death: Heart Attact
SOCIAL HISTORY:
Substance Abuse:
Alcohol: None FoundLast ALCOHOL/DRUG HF: CAGE 0/4 - xxxxxxx
Tobacco: CURRENT SMOKER, EVERY DAY - xxxxxxx
PHYSICAL EXAM:
Vital Signs: WT:191.00 (86.71 kg), HT:67.00 (170.18 cm), BP:112/68, PU:63,
TMP:97.60 (36.4 C), O2:92[ ], RS:20
General Exam:
Well-developed, well nourished, with no signs of acute distress.
HEENT:
Normocephalic, non-traumatic. TM's are normal bilaterally. Pupils are
equal
and round, and react to light. Extraocular movements are intact.
Fundiscopic exam shows normal disc and vasculature. There is no
nasal congestion. The mouth shows moist mucous membranes.
Good dentition. The oropharynx is clear.
Neck:
Supple. Non-tender. There is no lymphadenopathy.
Lungs:
Clear to auscultation bilaterally.
Heart/CV Exam:
Regular rate and rhythm without murmurs or rubs.
Abdomen Exam:
Soft. Non-tender. Bowel sounds are positive.
There is no hepatosplenomegaly.
Extremities:
Full range of motion. No joint tenderness. Pulses 2+.
There is no cyanosis or edema.
ASSESSMENT:
1) HTN [P]
2) Hyperlipidemia
3) Depression
4) COPD NOS
5) Lumbosacral Spondylosis Without Myelopathy
6) Anxiety-Unspec.
7) Issue Of Repeat Prescriptions
PLAN:
1) Renew and continue all chronic medications as directed.
2) Check on referral status.
Today's Orders:
Renew ALBUTEROL HFA 90MCG/SPRAY INHL,ORAL 90MCG/ACTUAT INHALE TWO (2) PUFFS
BY MOUTH EVERY 4 HOURS AS NEEDED FOR BREATHING Quantity: 6.7 Days: 30 Refills:
6 *Chronic Med: YES Dispense as Written: NO Indication: Wheezing
Renew ASPIRIN TAB,EC 81MG TAKE ONE (1) TABLET BY MOUTH DAILY ATTACK TO
REDUCE RISK OF STROKE OR HEART ATTACK Quantity: 30 Days: 30 Refills: 6
*Chronic Med: YES
Renew BACLOFEN TAB 10MG TAKE ONE (1) TABLET BY MOUTH FOUR TIMES A DAY AS
NEEDED FOR MUSCLE SPASMS Quantity: 120 Days: 30 Refills: 6 *Chronic Med: NO
Dispense as Written: NO Indication: Spasms
Renew buPROPion TAB,SA 150MG TAKE ONE (1) TABLET BY MOUTH DAILY FOR
DEPRESSION Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES
Renew CARVEDILOL TAB 12.5MG TAKE ONE (1) TABLET BY MOUTH TWICE A DAY FOR
HEART Quantity: 60 Days: 30 Refills: 6 *Chronic Med: YES
Renew CITALOPRAM TAB 40MG TAKE ONE (1) TABLET BY MOUTH DAILY FOR
DEPRESSION Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES
Renew FLUTICASONE/SALMETEROL 100MCG/50MCG DISKUS INHALE ONE (1) PUFF BY
MOUTH TWICE A DAY FOR ASTHMA Quantity: 60 Days: 30 Refills: 6 *Chronic Med:
YES Dispense as Written: NO Indication: COPD
Renew GABAPENTIN CAP,ORAL 300MG TAKE TWO (2) CAPSULES BY MOUTH 3 TIMES A
DAY DROWSINESS* FOR NERVE PAIN *MAY CAUSE DROWSINESS* Quantity: 180 Days: 30
Refills: 6 *Chronic Med: YES
Renew LOSARTAN TAB 100MG TAKE ONE (1) TABLET BY MOUTH DAILY FOR HIGH
BLOOD PRESSURE Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES
Renew MELOXICAM TAB 7.5MG TAKE ONE (1) TABLET BY MOUTH EVERY DAY FOR
PAIN AND INFLAMMATION Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES
Renew NORTRIPTYLINE CAP,ORAL 25MG TAKE ONE (1) CAPSULE BY MOUTH AT BEDTIME
FOR DEPRESSION Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES
Renew OMEPRAZOLE CAP,EC 20MG TAKE ONE (1) CAPSULE BY MOUTH EVERY MORNING
FOR STOMACH Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES
Renew SIMVASTATIN TAB 80MG TAKE ONE (1) TABLET BY MOUTH EVERY EVENING FOR
HIGH CHOLESTEROL Quantity: 30 Days: 30 Refills: 6 *Chronic Med: YES Dispense
as Written: NO Indication: hyperlipidemia
Follow-up: as directed.
/
Signed: xxxxxx
PROVIDER SELECTED 99212 AS the E/M code and as the diagnosis listed he
401.1 as primary then 272.4,311.,496.,721.3,300.00
The coder did not change anything .... is this correct ?
pt has medicare, so am I to only bill using the 401.1 dx.....?
