My provider is insisting that a 99214 is appropriate for the following visit even though she did not complete Review of Systems as time trumps these components. I have now notices that time hasn't been documented either! Does anyone know if this is true? If there is no ROS where does that leave me for an E/M?
Subjective
HPI Patient is a 61 year old male in for follow up on lab work. No concerns or changes since his last visit.
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No current outpatient prescriptions on file prior to visit.
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No current facility-administered medications on file prior to visit.
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No Known Allergies
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ROS NA
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Objective
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Vitals
There were no vitals filed for this visit.
Estimated body mass index is 29.61 kg/m² as calculated from the following:
Height as of 2/6/18: 5' 9.5" (1.765 m).
Weight as of 2/6/18: 203 lb 6.4 oz (92.3 kg).
Facility age limit for growth percentiles is 20 years.
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Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. No distress.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Eyes: Conjunctivae are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge.
Pulmonary/Chest: Effort normal.
Neurological: He is alert and oriented to person, place, and time. Coordination normal.
Skin: Skin is warm and dry.
Psychiatric: He has a normal mood and affect. His behavior is normal. Judgment normal.
Vitals reviewed.
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Lab: See Care Everywhere - he gets his labs through GRH - Union clinic
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Assessment and Plan
Patient is a 61 year old male in for follow up on his blood work. He has seen his chemical toxin screen and is working on detoxifying with dietary changes and lifestyle changes. His estradiol is a little high and this speaks to that fact that he is producing a little too much aromatase and converting his DHEA or testosterone to estrogen. Decreasing the insulin in his system through a lower carbohydrate diet will help this. His cholesterol panel is good. He has not signs of diabetes. His homocysteine level is high normal so he needs an MTHFR and this was drawn today. He looked a little dry on his CBC. Will monitor. His vitamin D is low and he will start replacement.
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E72.11 Elevated homocysteine (HCC) (primary encounter diagnosis)
Plan : COLLECTION, VENOUS BLOOD, VENIPUNCTURE
MTHFR DNA MUTATION ANALYSIS
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Patient Instructions
I will call you with blood test results.
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Take Vitamin D3 10,000 - daily for at least 4 months and recheck.
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You should here from **** to get your sleep study done.
Subjective
HPI Patient is a 61 year old male in for follow up on lab work. No concerns or changes since his last visit.
*
No current outpatient prescriptions on file prior to visit.
*
No current facility-administered medications on file prior to visit.
*
No Known Allergies
*
*
ROS NA
*
*
*
Objective
*
Vitals
There were no vitals filed for this visit.
Estimated body mass index is 29.61 kg/m² as calculated from the following:
Height as of 2/6/18: 5' 9.5" (1.765 m).
Weight as of 2/6/18: 203 lb 6.4 oz (92.3 kg).
Facility age limit for growth percentiles is 20 years.
*
*
Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. No distress.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Eyes: Conjunctivae are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge.
Pulmonary/Chest: Effort normal.
Neurological: He is alert and oriented to person, place, and time. Coordination normal.
Skin: Skin is warm and dry.
Psychiatric: He has a normal mood and affect. His behavior is normal. Judgment normal.
Vitals reviewed.
*
Lab: See Care Everywhere - he gets his labs through GRH - Union clinic
*
*
Assessment and Plan
Patient is a 61 year old male in for follow up on his blood work. He has seen his chemical toxin screen and is working on detoxifying with dietary changes and lifestyle changes. His estradiol is a little high and this speaks to that fact that he is producing a little too much aromatase and converting his DHEA or testosterone to estrogen. Decreasing the insulin in his system through a lower carbohydrate diet will help this. His cholesterol panel is good. He has not signs of diabetes. His homocysteine level is high normal so he needs an MTHFR and this was drawn today. He looked a little dry on his CBC. Will monitor. His vitamin D is low and he will start replacement.
*
E72.11 Elevated homocysteine (HCC) (primary encounter diagnosis)
Plan : COLLECTION, VENOUS BLOOD, VENIPUNCTURE
MTHFR DNA MUTATION ANALYSIS
*
*
Patient Instructions
I will call you with blood test results.
*
Take Vitamin D3 10,000 - daily for at least 4 months and recheck.
*
You should here from **** to get your sleep study done.
