snjberry
Networker
I don't believe this note supports an E&M charge for nasal discharge and parent says when she brought child he had no URI symptoms. Please give me an opinion on the below note. thank you
Subjective:
Chief Complaint(s):
hpv#3, flu shot
HPI:
Accompanied by: Mom .
10 year old male with mild URI symptoms. No fever. Good PO, active. Currently in grade 5 with Ms. --, enjoying football.
Current Medication:
None
Medical History:
No Medical History.
Allergies/Intolerance:
N.K.D.A.
Surgical History:
Denies Past Surgical History
Hospitalization:
Denies Past Hospitalization
Family History:
Social History:
Tobacco Use:
no Smoking .
ROS:
Objective:
Vitals:
Temp 98.5, HR 84, RR 20, Wt 141, Ht 58.5, BMI 28.96, BMI Percentile 99.03
Past Results:
Examination:
Pediatric Male
GENERAL: well developed, well nourished, NAD.
SKIN: no rashes.
HEAD: normocephalic.
EYES: sclera w/o injection.
EARS: TM's normal bilaterally.
NOSE: nasal discharge.
ORAL CAVITY: moist mucus membranes, tonsils normal.
NECK: supple, full range of motion.
CHEST: good air exchange bilaterally, no grunting, retractions, pink room air.
HEART: no murmurs, regular rate and rhythm.
ABDOMEN: soft, no hepatosplenomegaly.
EXTREMITIES: all move well.
NEUROLOGIC EXAM: intact.
Physical Examination:
Assessment:
Assessment:
URI (upper respiratory infection) - 465.9 (Primary)
Need for prophylactic vaccination and inoculation against influenza - V04.81
Need for HPV vaccination - V04.89
Plan:
Treatment:
URI (upper respiratory infection)
Notes: Symptomatic care.
Need for prophylactic vaccination and inoculation against influenza
Notes: Immunization as noted.
Need for HPV vaccination
Notes: Immunization as noted.
Procedures:
Immunizations:
VFC - Influenza, quadrivalent, split, preservative free, 3 yrs & >, IM : 0.5 mL given by on Right Deltoid.
VFC - HPV, types 6, 11, 16, 18 (quadrivalent) 3 dose schedule, IM : 0.5 mL (Dose No:2) given by on Right Deltoid.
Immunization record has been reviewed and updated.
Therapeutic Injections:
Diagnostic Imaging:
Lab Reports:
Preventive Medicine:
Disposition & Communication:
Next Appointment:
4 Months
Billing Information:
Visit Code:
99213 Office Visit, Est Pt., Level 3. Modifiers: 25
Procedure Codes:
90686 VFC - Influenza, quadrivalent, split, preservative free, 3 yrs & >, IM. Modifiers: SL
90649 VFC - HPV, types 6, 11, 16, 18 (quadrivalent) 3 dose schedule, IM. Modifiers: SL
90471 IMMUNIZATION ADMIN.
90472 IMMUNIZATION ADMIN, EACH ADD.
Subjective:
Chief Complaint(s):
hpv#3, flu shot
HPI:
Accompanied by: Mom .
10 year old male with mild URI symptoms. No fever. Good PO, active. Currently in grade 5 with Ms. --, enjoying football.
Current Medication:
None
Medical History:
No Medical History.
Allergies/Intolerance:
N.K.D.A.
Surgical History:
Denies Past Surgical History
Hospitalization:
Denies Past Hospitalization
Family History:
Social History:
Tobacco Use:
no Smoking .
ROS:
Objective:
Vitals:
Temp 98.5, HR 84, RR 20, Wt 141, Ht 58.5, BMI 28.96, BMI Percentile 99.03
Past Results:
Examination:
Pediatric Male
GENERAL: well developed, well nourished, NAD.
SKIN: no rashes.
HEAD: normocephalic.
EYES: sclera w/o injection.
EARS: TM's normal bilaterally.
NOSE: nasal discharge.
ORAL CAVITY: moist mucus membranes, tonsils normal.
NECK: supple, full range of motion.
CHEST: good air exchange bilaterally, no grunting, retractions, pink room air.
HEART: no murmurs, regular rate and rhythm.
ABDOMEN: soft, no hepatosplenomegaly.
EXTREMITIES: all move well.
NEUROLOGIC EXAM: intact.
Physical Examination:
Assessment:
Assessment:
URI (upper respiratory infection) - 465.9 (Primary)
Need for prophylactic vaccination and inoculation against influenza - V04.81
Need for HPV vaccination - V04.89
Plan:
Treatment:
URI (upper respiratory infection)
Notes: Symptomatic care.
Need for prophylactic vaccination and inoculation against influenza
Notes: Immunization as noted.
Need for HPV vaccination
Notes: Immunization as noted.
Procedures:
Immunizations:
VFC - Influenza, quadrivalent, split, preservative free, 3 yrs & >, IM : 0.5 mL given by on Right Deltoid.
VFC - HPV, types 6, 11, 16, 18 (quadrivalent) 3 dose schedule, IM : 0.5 mL (Dose No:2) given by on Right Deltoid.
Immunization record has been reviewed and updated.
Therapeutic Injections:
Diagnostic Imaging:
Lab Reports:
Preventive Medicine:
Disposition & Communication:
Next Appointment:
4 Months
Billing Information:
Visit Code:
99213 Office Visit, Est Pt., Level 3. Modifiers: 25
Procedure Codes:
90686 VFC - Influenza, quadrivalent, split, preservative free, 3 yrs & >, IM. Modifiers: SL
90649 VFC - HPV, types 6, 11, 16, 18 (quadrivalent) 3 dose schedule, IM. Modifiers: SL
90471 IMMUNIZATION ADMIN.
90472 IMMUNIZATION ADMIN, EACH ADD.