E/M Level 99215?

cnramsey

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Just double checking I feel this document supports a 99215. Am I wrong??

CC: Multi issues. Rectal bleeding.

History of Present Illness:
She is here after having rectal bleeding twice yesterday. She was afraid it was due to her Coumadin, so quit taking it yesterday. She says she looked and didn't see hemorrhoid or fissure, has not had pain or itching. She is worried because her daughter has Crohn's and has had surgeries in the past.

She is having more problems with depression. She says it "bad, so bad I should be hospitalized but I don't want to go to the hospital." She finally has a counsellor coming to the house. She says she is upset because of all the things she is missing. She can't go to school functions or Cub Scouts and she is afraid her son thinks she doesn't love him. She says she can't leave the house, this is the first time she has been out in 3 months. Her son has several appointments in Spokane and she is unable to go at this point because her panic disorder is so bad. She can't go to school, can't pick up her own meds, can't do her own grocery shopping. She is not bathing because she just doesn't want to. Her husband has to take time off work to do things for her and she is concerned about his job. She is trying to get a care worker to assist with some activities, like shopping and cleaning. She is concerned Medicaid will put a lien on her house if she gets services. She wants a note from me stating she needs services. She says Wellbutrin makes her suicidal, Zoloft & Cymbalta didn't work, but thinks she does need to be back on something.

She has left knee pain. She says it makes a clunk or grinding noise at times. She has pain in her left foot, right shoulder, neck. She has been unable to see a rheumatologist.

She never kept appt for cervical injection. The nurse told her there was a 1:5000 risk of paralysis, so she cancelled. The pain is terrible and she is now considering doing it.

She has had some chest congestion, head congestion. No sore throat or earache. No fever or chills.

Past Medical History:
migraines
agoraphobia/panic disorder
depression
asthma
tobaccoism
h/o hyperthyroidism
sleep apnea
DVT left leg 7/11
DJD cervical spine
arthritis
vit D deficiency

Past Surgical History:
tonsillectomy
C/S x2
breast augmentation 1883, revision 2007
R eye palpebral reduction for Graves disease.

Review of Systems

General
Complains of fatigue and malaise.
Denies fever and chills.

Eyes
Denies eye irritation, blurring, and discharge.

ENT
Complains of nasal congestion.
Denies earache, hoarseness, and sore throat.

Resp
Complains of cough, shortness of breath, and wheezing.

GI
Complains of bloody stools.
Denies vomiting, abdominal pain, hemorrhoids, diarrhea, and dark tarry stools.

GU
Denies blood in urine, urinary frequency, urinary urgency, painful urination, and other abnormal vaginal bleeding.

MS
Complains of joint pain, back pain, stiffness, arthritis, and muscle aches.

Derm
Complains of dryness.
Denies itching and rash.

Neuro
Denies numbness, tingling, seizures, and tremors.

Psych
Complains of anxiety, thoughts of suicide, and depression.
Denies thoughts of violence and frightening visions or sounds.

Heme
Complains of bleeding.
Denies enlarged lymph nodes and abnormal bruising.

Vital Signs:

Patient Profile: Years Old Female
Height: 69.50 inches
Weight: pounds
Temp: 95.6 degrees F tympanic
Pulse rate: 88 / minute
Pulse rhythm: regular
Resp: 18 per minute
BP sitting: 132 / 84 (left arm)
Cuff size: large

Vitals Entered By:

Physical Exam

General:
well developed, well nourished, in no acute distress.
Ears:
TM's intact and clear with normal canals with grossly normal hearing.
Mouth:
post nasal drip.
Neck:
no masses, thyromegaly, or abnormal cervical nodes.
Lungs:
coarse, few wheezes, no ronchi
Heart:
regular rhythm, normal rate, no murmurs, and no rubs.
Abdomen:
active bowel sounds, soft, non-distended, nontender to palpation, no masses
Rectal:
declined
Msk:
tender cervical and lumbar paraspinals, no spinous process tenderness
Extremities:
knees, ankles, feet, wrists, hands, elbows shoulders tender to palpation but without redness, warmth or swelling
Cervical Nodes:
no significant adenopathy.
Psych:
alert and cooperative; depressed mood and affect; normal attention span and concentration. Poorly groomed, hair is unwashed. Wearing make up and perfume, but clothing is dirty. No pressured speech or flight of ideas. Has had thoughts that things would be easier if she were not here, but has not had any specific suicidal ideation or plans. No visual or auditory hallucinations.


Impression & Recommendations:

Problem # 1: MAJOR DPRSV DISORDER RECURRENT EPISODE MODERATE (ICD-296.32)
She has tried several medications in the past. Now, finally, has counselling in place, which can also improve symptoms. Will try Pristiq daily to see if she can tolerate it. F/U in1 month

Problem # 2: AGORAPHOBIA WITH PANIC DISORDER (ICD-300.21)
continue counselling. Try to minimize benzo use, as she is developing some tolerance and certainly has some dependence.

Problem # 3: BLOOD IN STOOL (ICD-578.1)
Does have family history of Crohn's and has not had a colonoscopy. Referral placed.

Orders:
Colonoscopy (COLONOS)


Problem # 4: DEGENERATIVE JOINT DISEASE, CERVICAL SPINE (ICD-721.90)
Discussed again the risk of injections being minimal, especially with fluorscopic guidance used now. She will contact to schedule

Problem # 5: PAIN IN JOINT, MULTIPLE SITES (ICD-719.49)
She has hydrocodone. She continues to work with referrals office to try to get rheum appt. No evidence of synovitis on evam and labs have been negtive in the past. More likely osteoarthritis, so need for rhem appt is not pressing

Problem # 6: UPPER RESPIRATORY INFECTION (ICD-465.9)
Lungs about at baseline. Encouraged again to quit smoking. If she worsens, develops fever, etc, needs to be reevaluated.

Her updated medication list for this problem includes:
Loratadine 10 Mg Tabs (Loratadine) ..... 1 qd


Medications Added to Medication List This Visit:
1) Pristiq 50 Mg Xr24h-tab (Desvenlafaxine succinate) .... 1 tab po once daily daw1, tried and failed zoloft, wellbutrin, can't take cymbalta or citalopram because she is on warfarin

Prescriptions:
PRISTIQ 50 MG XR24H-TAB (DESVENLAFAXINE SUCCINATE) 1 tab PO once daily DAW1, tried and failed Zoloft, Wellbutrin, can't take Cym
 
Last edited:

rojko

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CNRAMSEY, It might be wise if , in the future, you do not include a physician's name when posting medical records.
 
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