mlemon
Networker
I have a physician who is questioning the level of service he is getting for his office visits. I have done an audit sheet on his office notes but would like a couple of opinions from other CPCs also. Any help would be greatly appreciated.
What code do you get for these office notes?
******#1*******
PROGRESS NOTE:
The patient is a 79-year-old man with metastatic squamous cell carcinoma of the head and neck region. The primary site of disease has never been identified. He had significant progression in the left lower neck region and then the development of multiple bilateral pulmonary nodules. He has received numerous chemotherapeutic regimens but has not responded to any of them. He does have a PEG in place through which he gets most of his nutrition. He does have problems with aspiration because of vocal cord paralysis. The patient returns today stating that he has not been doing well. He continues to lose weight. He has no significant pain but does have problems managing upper airway secretions. In addition, his PEG is apparently clogged off, and he is to have that irrigated in the emergency room later today.
PHYSICAL EXAMINATION:
On examination his weight was down 12 pounds since I saw him about 8 weeks ago. His mucous membranes are slightly dry, and he has developed crusted lesions on his scalp.
DIAGNOSTIC STUDIES:
Imaging
A chest x-ray today reveals significant progression of his pulmonary nodules.
ASSESSMENT:
He has had marked progression of his disease associated with a deterioration in his performance status. We have talked about death and dying. He does have home health care, but I have suggested that they consider hospice, and they will call me when they are ready to proceed with that type of management. His Port-A-Cath was irrigated today, and I will see him on a p.r.n. basis. He understands his poor prognosis.
*********#2********
PROGRESS NOTE:
The patient is a 49-year-old woman who in January 2007 presented to University Hospital with severe hypercalcemia. She had widespread metastatic disease to bone with multiple destructive lesions. Bone biopsy was suggestive of a primary breast cancer. Estrogen receptor was positive. A mammogram was obtained which revealed a lesion in the left breast that was not palpable. She was treated with I.V. hydration and Zometa with normalization of her serum calcium. She was then placed on MS Contin and MS elixir and received radiation therapy to several areas where she had been having severe pain. Hormonal therapy with tamoxifen was initiated. She has done extremely well on this regimen, with a dramatic improvement in her performance status. She does, however, continue to require MS Contin 60 mg every 8 hours and uses MS elixir occasionally for breakthrough. Her last staging evaluation was in April
2009 which included a negative chest x-ray and a bone scan which was completely normal. This was a dramatic improvement over previous scans. The patient returns today for followup. She states she continues to feel quite well. Appetite and weight are stable. Her bone pain remains under adequate control with the current analgesic regimen. There is no chest discomfort, sputum production, or hemoptysis. No complaints of abdominal pain or change in bowel habits. The rest of the ten-system review of systems was negative.
PHYSICAL EXAMINATION:
GENERAL: The patient appears to be a well-developed, well-nourished woman in no acute distress. VITAL SIGNS: Examination of the vital signs revealed them to be stable per flow sheet. HEENT: Unremarkable. The throat was clear; the mucous membranes were moist; and the sclerae were not icteric. NECK: Supple. CHEST: Clear to auscultation and percussion. CARDIOVASCULAR: Did not reveal any jugular venous distention, murmurs, gallops, or rubs. LYMPH NODE SURVEY: Did not reveal any peripheral lymphadenopathy. BREASTS: Did not reveal any masses. ABDOMEN: Revealed it to be soft and nontender. There was no hepatomegaly, splenomegaly, or any other masses or ascites. Bowel sounds were normal. EXTREMITIES: Did not reveal any clubbing, cyanosis, or edema. SKIN: Examination revealed no abnormal lesions and normal turgor. NEUROLOGIC: Did not reveal any focal findings.
ASSESSMENT:
She continues to do remarkably well and has had an excellent response to hormonal therapy. She will continue with tamoxifen and monthly Zometa, which she will receive today. She will return in 1 month for followup.
*******#3******
PROGRESS NOTE:
The patient is a 46-year-old man with metastatic gastric cancer. He has received a variety of chemotherapeutic regimens. The most recent was cisplatin and irinotecan. He received 3 cycles of this therapy and was restaged and found to have an improvement with a decrease in the size of his hepatic metastases seen on CT scan of the liver. However, recently he has developed poor appetite and weight loss associated with increasing nausea. He has also been noted to have a marked elevation of his bilirubin to greater than 20. He had a restaging evaluation last week with a whole-body
PET scan which revealed marked progression of disease throughout his body with extensive infiltration of his liver.
The patient returns today stating that he is doing very poorly. Pain has not been a major issue but weakness and poor oral intake has been a problem. He has lost 21 pounds over the past week.
PHYSICAL EXAMINATION:
VITAL SIGNS: He was afebrile with a resting tachycardia. His blood pressure was normal. HEENT: He had scleral icterus. ABDOMEN: Examination of the abdomen revealed hepatomegaly.
ASSESSMENT:
He is rapidly deteriorating due to a marked progression of disease. I have explained this to the patient and his family, and I have told him that his prognosis is extremely poor at this time. He wanted something to help with his nausea and therefore will be given I.V. hydration along with Decadron and Anzemet. I did discuss consultation with hospice with him and his family, and they are agreeable to that. His prognosis is poor, and he will return on a p.r.n. basis.
What code do you get for these office notes?
******#1*******
PROGRESS NOTE:
The patient is a 79-year-old man with metastatic squamous cell carcinoma of the head and neck region. The primary site of disease has never been identified. He had significant progression in the left lower neck region and then the development of multiple bilateral pulmonary nodules. He has received numerous chemotherapeutic regimens but has not responded to any of them. He does have a PEG in place through which he gets most of his nutrition. He does have problems with aspiration because of vocal cord paralysis. The patient returns today stating that he has not been doing well. He continues to lose weight. He has no significant pain but does have problems managing upper airway secretions. In addition, his PEG is apparently clogged off, and he is to have that irrigated in the emergency room later today.
PHYSICAL EXAMINATION:
On examination his weight was down 12 pounds since I saw him about 8 weeks ago. His mucous membranes are slightly dry, and he has developed crusted lesions on his scalp.
DIAGNOSTIC STUDIES:
Imaging
A chest x-ray today reveals significant progression of his pulmonary nodules.
ASSESSMENT:
He has had marked progression of his disease associated with a deterioration in his performance status. We have talked about death and dying. He does have home health care, but I have suggested that they consider hospice, and they will call me when they are ready to proceed with that type of management. His Port-A-Cath was irrigated today, and I will see him on a p.r.n. basis. He understands his poor prognosis.
*********#2********
PROGRESS NOTE:
The patient is a 49-year-old woman who in January 2007 presented to University Hospital with severe hypercalcemia. She had widespread metastatic disease to bone with multiple destructive lesions. Bone biopsy was suggestive of a primary breast cancer. Estrogen receptor was positive. A mammogram was obtained which revealed a lesion in the left breast that was not palpable. She was treated with I.V. hydration and Zometa with normalization of her serum calcium. She was then placed on MS Contin and MS elixir and received radiation therapy to several areas where she had been having severe pain. Hormonal therapy with tamoxifen was initiated. She has done extremely well on this regimen, with a dramatic improvement in her performance status. She does, however, continue to require MS Contin 60 mg every 8 hours and uses MS elixir occasionally for breakthrough. Her last staging evaluation was in April
2009 which included a negative chest x-ray and a bone scan which was completely normal. This was a dramatic improvement over previous scans. The patient returns today for followup. She states she continues to feel quite well. Appetite and weight are stable. Her bone pain remains under adequate control with the current analgesic regimen. There is no chest discomfort, sputum production, or hemoptysis. No complaints of abdominal pain or change in bowel habits. The rest of the ten-system review of systems was negative.
PHYSICAL EXAMINATION:
GENERAL: The patient appears to be a well-developed, well-nourished woman in no acute distress. VITAL SIGNS: Examination of the vital signs revealed them to be stable per flow sheet. HEENT: Unremarkable. The throat was clear; the mucous membranes were moist; and the sclerae were not icteric. NECK: Supple. CHEST: Clear to auscultation and percussion. CARDIOVASCULAR: Did not reveal any jugular venous distention, murmurs, gallops, or rubs. LYMPH NODE SURVEY: Did not reveal any peripheral lymphadenopathy. BREASTS: Did not reveal any masses. ABDOMEN: Revealed it to be soft and nontender. There was no hepatomegaly, splenomegaly, or any other masses or ascites. Bowel sounds were normal. EXTREMITIES: Did not reveal any clubbing, cyanosis, or edema. SKIN: Examination revealed no abnormal lesions and normal turgor. NEUROLOGIC: Did not reveal any focal findings.
ASSESSMENT:
She continues to do remarkably well and has had an excellent response to hormonal therapy. She will continue with tamoxifen and monthly Zometa, which she will receive today. She will return in 1 month for followup.
*******#3******
PROGRESS NOTE:
The patient is a 46-year-old man with metastatic gastric cancer. He has received a variety of chemotherapeutic regimens. The most recent was cisplatin and irinotecan. He received 3 cycles of this therapy and was restaged and found to have an improvement with a decrease in the size of his hepatic metastases seen on CT scan of the liver. However, recently he has developed poor appetite and weight loss associated with increasing nausea. He has also been noted to have a marked elevation of his bilirubin to greater than 20. He had a restaging evaluation last week with a whole-body
PET scan which revealed marked progression of disease throughout his body with extensive infiltration of his liver.
The patient returns today stating that he is doing very poorly. Pain has not been a major issue but weakness and poor oral intake has been a problem. He has lost 21 pounds over the past week.
PHYSICAL EXAMINATION:
VITAL SIGNS: He was afebrile with a resting tachycardia. His blood pressure was normal. HEENT: He had scleral icterus. ABDOMEN: Examination of the abdomen revealed hepatomegaly.
ASSESSMENT:
He is rapidly deteriorating due to a marked progression of disease. I have explained this to the patient and his family, and I have told him that his prognosis is extremely poor at this time. He wanted something to help with his nausea and therefore will be given I.V. hydration along with Decadron and Anzemet. I did discuss consultation with hospice with him and his family, and they are agreeable to that. His prognosis is poor, and he will return on a p.r.n. basis.