We are having our first audit and I would like some input. The Dr. coded this visit a level 3 established pt 99213. Do you think this note qualifies?
Cardiac Problems:
PAF
Symptoms:
He continues to do well and is not limited in his activities. He has been getting regular exercise with a stationary bike or treadmill. He had a normal stress echo (4/07) and a cath that showed only minimal non obstructive CAD(6/07)
Meds:
His meds are listed here but for my question i am not going to list them all
Physical Exam:
Vitals=wt 176, bp: 110/70;pulse 72 resp 18
Appearance: well developed, no distress
HEENT: normocephalic, atraumatic
Chest: clear to percussion, auscultation, no rales, no wheezes
Cardiovascular: Jugular Venous pressure, normal, Heart rhythm reugular, no mumur, rub or gallop notes. Vascular exam, lower extremity pulses are 2+ out of 4 in both legs
Abdomen: soft, non tender. Bowel sounds present.
Extremity: No cyanosis, clubbing or edema
Neuro: Nonfocal exam, normal strenght, movement/balance
Labs/Dats: ECG from today NSR, no acute ischemic changes
Assessment and Plan:
He is doing well on his current meds and is currently in sinus rhythm. I would not make any changes in his cardiac meds at this time. i will schedule him for a f.u in about 1 year.
What do you all think. The dx codes used were 427.31 and 414.01. THanks in advance
Cardiac Problems:
PAF
Symptoms:
He continues to do well and is not limited in his activities. He has been getting regular exercise with a stationary bike or treadmill. He had a normal stress echo (4/07) and a cath that showed only minimal non obstructive CAD(6/07)
Meds:
His meds are listed here but for my question i am not going to list them all
Physical Exam:
Vitals=wt 176, bp: 110/70;pulse 72 resp 18
Appearance: well developed, no distress
HEENT: normocephalic, atraumatic
Chest: clear to percussion, auscultation, no rales, no wheezes
Cardiovascular: Jugular Venous pressure, normal, Heart rhythm reugular, no mumur, rub or gallop notes. Vascular exam, lower extremity pulses are 2+ out of 4 in both legs
Abdomen: soft, non tender. Bowel sounds present.
Extremity: No cyanosis, clubbing or edema
Neuro: Nonfocal exam, normal strenght, movement/balance
Labs/Dats: ECG from today NSR, no acute ischemic changes
Assessment and Plan:
He is doing well on his current meds and is currently in sinus rhythm. I would not make any changes in his cardiac meds at this time. i will schedule him for a f.u in about 1 year.
What do you all think. The dx codes used were 427.31 and 414.01. THanks in advance