heatherwinters
Expert
How would you code this visit? E/M or Preventative. If Preventative, can I get away with coding an additional E/M based on evaluation of patient for insomnia and subsequent prescription? Insomnia is has been a problem since visit the year before. The lack of HPI and ROS is what bothers me about coding the visit. No Comprehensive History component.
CC: Annual PE and Pt would like referral for Vasectomy
HPI: Wife wants to go off pill. Interested in birth Control
PMH: Lumbar Disc Disease
Surg Hx: 0
Allergies: NKDA
Social H: Married, No tobacco use, alcohol socially
ROS: sleep problems
Vitals Documented
Exam:
General: Normal
Head: Normal
Eyes: Normal
Neck: Normal
Chest: Normal
Breasts: Normal
CV: Normal
Abdomen: Normal
Back: Full ROM, non tender
Ext: Normal
Skin: Normal
Neuro: Normal
Assessment: Family Planning, Insomnia, Lumbar Disc Disease
Plan: Urology Consult, Lunesta RX
Thanks for your input.
CC: Annual PE and Pt would like referral for Vasectomy
HPI: Wife wants to go off pill. Interested in birth Control
PMH: Lumbar Disc Disease
Surg Hx: 0
Allergies: NKDA
Social H: Married, No tobacco use, alcohol socially
ROS: sleep problems
Vitals Documented
Exam:
General: Normal
Head: Normal
Eyes: Normal
Neck: Normal
Chest: Normal
Breasts: Normal
CV: Normal
Abdomen: Normal
Back: Full ROM, non tender
Ext: Normal
Skin: Normal
Neuro: Normal
Assessment: Family Planning, Insomnia, Lumbar Disc Disease
Plan: Urology Consult, Lunesta RX
Thanks for your input.