ebredehoeft
Networker
PLease tell me what you think.
Doctor documented as a follow up visit and then also performed what appears like a preventive visit.
31 year old returns for follow up
#1 Anxiety Has been taking Citalopram and is noticing much less anxiety. Feels exhausted from the holidays. Had a panic attack yesterday with a feeling of doom and feeling tense and heart raced at times. Had sweaty palms. This lasted a few hours and went away. No suicidal thoughts. Feels coping with life better. Feels more patient and less irritable. Dtr. Reports that there is less yelling. Her motivation is improved
#2 Insomnia Has taken the Desyrel at bedtime about three times. Has taken a whole tab and is sleeping through the night. Has no adverse side effects like dry mouth.
#3 Asthma States had one asthma attack and used inhaler and took a big glass of cold water and was much improved. Has rarely used inhaler since her viral infection resolved.
#4 Tobaccoism Plans to stop smoking when she gets her teeth pulled Has first appt for this 1/7. Looking at early February for quit date.
#5 Health maintenance. No Pap for 7 years. G5 P4 TAB1 Does not do BSE. LMP12/18/10 Periods last 3-5 days. And occur q. 2.5 to 3 weeks . BCM tubal ligation 2004 Not sexually active for a few months. Left partner of 10 years who had other sexual partners so wants GC and chylamydia and HIV test . Has had Tdap in last 10 years.
#6 Eczema Never filled Hydrocortisone RX so can not comment if it helped her eczema.
HPI
Review of Systems
Constitutional: Negative for fever, chills, weight loss and malaise/fatigue.
HENT: Negative for ear pain, nosebleeds, congestion, sore throat, neck pain, tinnitus and ear discharge.
Teeth in poor repair; will have dentures.
Eyes: Negative for blurred vision and double vision.
Respiratory: Negative for cough, sputum production, shortness of breath and wheezing.
Cardiovascular: Negative for chest pain and palpitations.
Gastrointestinal: Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea and constipation.
Genitourinary: Negative for dysuria and frequency.
Musculoskeletal: Negative for myalgias and back pain.
Skin: Negative for itching.
Has eczema on ears and hands
Neurological: Negative for dizziness, tingling, tremors and headaches.
Endo/Heme/Allergies: Negative for environmental allergies. Does not bruise/bleed easily.
Psychiatric/Behavioral: Negative for depression, suicidal ideas and hallucinations. The patient is nervous/anxious. The patient does not have insomnia.
Physical Exam
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished.
HENT:
Head: Normocephalic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Nose: Nose normal.
Mouth/Throat: Oropharynx is clear and moist.
Eyes: Conjunctivae and extraocular motions are normal. Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. Neck supple. No thyromegaly present.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes. She has no rales.
Abdominal: Soft. Bowel sounds are normal. She exhibits no distension. No tenderness. She has no rebound and no guarding.
Genitourinary: Vagina normal and uterus normal. No discharge found.
Musculoskeletal: Normal range of motion. She exhibits no edema and no tenderness.
Lymphadenopathy:
She has no cervical adenopathy.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm and dry. Rash (scaley erythematous rash on tops of ears and on hands) noted.
Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment and thought content normal.
Assessment and Plan: V76.2 Screening for malignant neoplasm of the cervix
Plan : CYTOPATH C/V LIQUID-BASED
V76.11 Screening mammogram for high-risk patient
V70.0 Routine general medical examination at a health care facility
Plan : HIV-1 & HIV-2 ANTIBODIES
CHLAMYDIA/GC, DNA PROBE W/CONFIRMATION
300.00 Anxiety state, unspecified
Plan : HYDROXYZINE 25 MG TAB - 1 -2 pills q. 6 hours
po prn anxiety or panic attack
CITALOPRAM 20 MG TAB - one daily
305.1 Tobacco use disorder
Encouraged to come back in February to reinforce quit plan
More than 50% of visit in counseling and coordination of care re:smoking cessation, safe sex, healthy diet and exercise, BSE education and asthma education
With this info would we bill a preventive plus a problem focus for the other issues or would it all be wrapped up into one code?
Thanks,
Doctor documented as a follow up visit and then also performed what appears like a preventive visit.
31 year old returns for follow up
#1 Anxiety Has been taking Citalopram and is noticing much less anxiety. Feels exhausted from the holidays. Had a panic attack yesterday with a feeling of doom and feeling tense and heart raced at times. Had sweaty palms. This lasted a few hours and went away. No suicidal thoughts. Feels coping with life better. Feels more patient and less irritable. Dtr. Reports that there is less yelling. Her motivation is improved
#2 Insomnia Has taken the Desyrel at bedtime about three times. Has taken a whole tab and is sleeping through the night. Has no adverse side effects like dry mouth.
#3 Asthma States had one asthma attack and used inhaler and took a big glass of cold water and was much improved. Has rarely used inhaler since her viral infection resolved.
#4 Tobaccoism Plans to stop smoking when she gets her teeth pulled Has first appt for this 1/7. Looking at early February for quit date.
#5 Health maintenance. No Pap for 7 years. G5 P4 TAB1 Does not do BSE. LMP12/18/10 Periods last 3-5 days. And occur q. 2.5 to 3 weeks . BCM tubal ligation 2004 Not sexually active for a few months. Left partner of 10 years who had other sexual partners so wants GC and chylamydia and HIV test . Has had Tdap in last 10 years.
#6 Eczema Never filled Hydrocortisone RX so can not comment if it helped her eczema.
HPI
Review of Systems
Constitutional: Negative for fever, chills, weight loss and malaise/fatigue.
HENT: Negative for ear pain, nosebleeds, congestion, sore throat, neck pain, tinnitus and ear discharge.
Teeth in poor repair; will have dentures.
Eyes: Negative for blurred vision and double vision.
Respiratory: Negative for cough, sputum production, shortness of breath and wheezing.
Cardiovascular: Negative for chest pain and palpitations.
Gastrointestinal: Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea and constipation.
Genitourinary: Negative for dysuria and frequency.
Musculoskeletal: Negative for myalgias and back pain.
Skin: Negative for itching.
Has eczema on ears and hands
Neurological: Negative for dizziness, tingling, tremors and headaches.
Endo/Heme/Allergies: Negative for environmental allergies. Does not bruise/bleed easily.
Psychiatric/Behavioral: Negative for depression, suicidal ideas and hallucinations. The patient is nervous/anxious. The patient does not have insomnia.
Physical Exam
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished.
HENT:
Head: Normocephalic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Nose: Nose normal.
Mouth/Throat: Oropharynx is clear and moist.
Eyes: Conjunctivae and extraocular motions are normal. Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. Neck supple. No thyromegaly present.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes. She has no rales.
Abdominal: Soft. Bowel sounds are normal. She exhibits no distension. No tenderness. She has no rebound and no guarding.
Genitourinary: Vagina normal and uterus normal. No discharge found.
Musculoskeletal: Normal range of motion. She exhibits no edema and no tenderness.
Lymphadenopathy:
She has no cervical adenopathy.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm and dry. Rash (scaley erythematous rash on tops of ears and on hands) noted.
Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment and thought content normal.
Assessment and Plan: V76.2 Screening for malignant neoplasm of the cervix
Plan : CYTOPATH C/V LIQUID-BASED
V76.11 Screening mammogram for high-risk patient
V70.0 Routine general medical examination at a health care facility
Plan : HIV-1 & HIV-2 ANTIBODIES
CHLAMYDIA/GC, DNA PROBE W/CONFIRMATION
300.00 Anxiety state, unspecified
Plan : HYDROXYZINE 25 MG TAB - 1 -2 pills q. 6 hours
po prn anxiety or panic attack
CITALOPRAM 20 MG TAB - one daily
305.1 Tobacco use disorder
Encouraged to come back in February to reinforce quit plan
More than 50% of visit in counseling and coordination of care re:smoking cessation, safe sex, healthy diet and exercise, BSE education and asthma education
With this info would we bill a preventive plus a problem focus for the other issues or would it all be wrapped up into one code?
Thanks,