Please read the note below. I am not very good at E/M coding and I need help. The provider has a site she calculates her E/M levels and this note is coming out as a 99203. (This is a new patient btw.) She spent about an hour with this patient and is confused as to why it isn't a 99204. HELP!!!
Current Medications
None
Past Medical History
Term birth, BW 6-14, healthy, breastfed
First 10 years - healthy, rare OM, no wheezing, no asthma
First grade - learning disability - IEP. Then, homeschooled for 2nd and 3rd grade
12/2013 - . Torus fracture right radius
2013 & 2014 Seen by ----------
2013 & 2014 - Anxiety, abdominal pain (AM & after lunch), gassiness, constipation & diarrhea
2013- Missed 30 days of school
Surgical History
Denies Past Surgical History
Family History
Father: alive No GI problems
Mother: alive No GI problems
Siblings: No GI illness
3 brother(s) , 1 sister(s) .
Possible GERD in the family. No known inflammatory bowel disease.
Social History
Lives With: Parents, and Siblings.
Language: English.
Country of Birth: U.S.
Pediatric Home safety measures: has smoke detector.
Tobacco Exposure: No.
Animal Exposures: no pets in the home.
Allergies
N.K.D.A.
Hospitalization/Major Diagnostic Procedure
Denies Past Hospitalization
Review of Systems
CC basic:
Sick contacts none. Brought by mother.
Reason for Appointment
1. pediactic Evaluation
History of Present Illness
Depression Screening:
PHQ-9 Thoughts that you would be better off dead, or of hurting yourself in some way Not at all, Total Score 10, Intepretation Moderate Depression.
Pediatric Mood :
Parents primary concern: Possible anxiety and abdominal pain. Mother wants to know more about why Morgan has abdominal pain. Missed school because of stomach problems - dx irritable bowel, or may have other issues. Diet is good, constipation. Goes to the BR a lot, but c/o constipation & diarrhea. Parental report on General Mood: She is not getting the right help for reading. She has not been diagnosed with dyslexia, but mother has dyslexia, and would like a multisensory approach. . School issues: LD - dyslexic, in resource. WISC V. Problems: Stomach pain before school, then the night before. Mother would like to know if there is a physical reason for the problems. She has vomited twice at school on one day. Normally, her tummy pain starts in the morning or after lunch. Pain is better is she eats fruit smoothies and green smoothies. Worse with school foods w/ whole wheat. She has excess burping, gas. No bloating. Sometimes it is better after going to the bathroom Sometimes is shopping, and will beg to go home with stomach pain. Mid to upper.
Sick:
c/o concerns about Prior evaluation 3/17/2014 -Child was evaluated 2 months prior diagnosed with, fluctuating constipation/diarrhea abdominal pain bloating gassiness improved with defecation. Recommendation increase fiber increased fluid. Patient has been instituting fiber fluid without significant improvement in abdominal pain and bloating. Assessment - Anxiety from learning disability; request pediatric psych eval potential treatment of anxiety.
Vital Signs
Pain scale 0, Wt 55.0 lbs, Ht 50.87 in, BMI Percentile 12.42, BMI 14.94, BP 120/72, Temp 97.7, HR 109, SaO2 97, Ht Percentile 3.98, Wt Percentile 2.19.
Examination
CC Pediatric Exam:
GENERAL APPEARANCE: Very petite, alert, quiet and pleasant girl who is cooperative with the exam. SKIN: no rashes, no skin lesions. HEAD: normocephalic. EYES: normal, sclera/conjunctiva clear. EARS: TMs: pearly gray, with good light reflection. NOSE: nares patent and clear, mucosa normal. ORAL CAVITY: moist mucous membranes, tonsils normal, pharynx without erythema or exudate. NECK: supple, no lymphadenopathy. HEART: RRR, no murmurs. LUNGS: clear, equal breath sounds bilaterally. ABDOMEN: soft, nontender, no masses. EXTREMITIES: moving all extremities equally. NEUROLOGIC EXAM: non-focal. OTHER Interpretation of drawing: She comes from a well-anchored situation. Whatever the learning disabilities are, they create a appearance of being of being less mature in manner (more like an 8.5 year old girl). She has a certain sense of helplessness in terms of her ability to cope, but 'covers up' with a cheery outlook. She is generally accessible to people, is not overly anxious or agitated. She seems to have some low self esteem and feels powerless, but still feels secure in her world and connected to the people who love her. Second picture does show some signs of depression showing up, in that the dogs have sad faces, even though the big, center bear has a happy face.
Assessments
1. Abdominal pain, periumbilic - 789.05 (Primary)
2. Abdominal pain, chronic, generalized - 789.07
3. Flatulence, eructation, and gas pain - 787.3, etiology unclear. First thoughts: Constipation, Giardia, lactose intolerance and celiac disease can all cause these symptoms.
4. Learning disabilities - 315.2, reading level > 3 years delayed, math delay
5. School avoidance - V62.3, secondary to physiologic abdominal pain or functional abd pain vs. anxiety
Treatment
1. Abdominal pain, periumbilic
Start Zantac (Ranitidine) liquid, 15 mg/mL, 5 ml, orally, BID, 30 days, 300 ml, Refills 3
LAB: Stool- Giardia Antigen
LAB: Complete Metabolic Panel (Ordered for 03/31/2014) Normal Calcium, Serum 9.7
Glucose, Serum 106
BUN 15
Protein, Total, Serum 7.2
Albumin, Serum 4.4
Bilirubin, Total 0.4
Alkaline Phosphatase, S 375
AST (SGOT) 13
Potassium, Serum 4.1
Sodium, Serum 140
Chloride, Serum 109
Creatinine, Serum 0.61
ALT (SGPT) 22
Carbon Dioxide, Total 24
140 4.1 109 24 7 106 15 0.61 9.7 7.2 4.4 0.4 375 13 22 .
LAB: TSH (Ordered for 03/31/2014) Normal 1.94 TSH 1.94
LAB: Celiac Disease Panel (Ordered for 03/31/2014)
LAB: Sedimentation Rate-Westergren (Ordered for 03/31/2014) 1 Sedimentation Rate-Westergren 1
LAB: Stool- Occult Blood Negative OCCULT BLOOD, STOOL neg
LAB: H. PYLORI AG, STOOL
LAB: Cryotosporidium antigen
FUNCTIONAL ABDOMINAL PAIN
1. Regular meals, including breakfast, and good nutrition are important
Breakfast everyday, plus 5 servings of fruit or vegetables
Avoid soda, chocolate, chips, Cheetos and other non-nutritious foods
If drinking milk makes the abdominal pain worse, then try Lactaid Milk or soy milk.
Consider other medications and health foods that have been shown to help with abdominal pain;
Lactobacillus GG (Culturelle) or L. reuteri, which have been studied. Other Lactobacillus combinations may also be helpful, if the first two are not availble or are too expensive.
Medication - Cyproheptadine - has been helpful for some children
Peppermint capsules have helped some children.
Relaation techiques may be helpful
If your child is not improving, keep an abdominal pain and diet diary and return to clinic for further evaluation. Also, watch for signs of constipation, which is very common, and treat if present.
2. Abdominal pain, chronic, generalized
Will plan to check for common causes, and consider KUB for constipation. She was not distended today. GI referral if abdominal pain does not improve.
3. Learning disabilities
Recommend WISC IV to evaluate reasoning, short term memory, non-verbal learning, etc.
4. School avoidance
Previously, anxiety thought to be the source of abdominal pain and missed school. Patient denies being bullied, but learning disorders put her at risk. Anxiety is a common cause of abdominal pain; If medical evaluation does not find a cause for pain, and a trial of dairy-free/glutin free foods does not help, then a trial of an anti-anxiety medication would be a reasonable next step.
Preventive Medicine
CC sick: F/u for new symptoms, poor oral intake, increased crying or pain, difficulty breathing, high fevers, weakness, changes, or if worse.
Face to face time with patient > 50 minutes, Education of patient/caregiver and co-ordination of care comprised 50% of the face-to-face appointment time.
Current Medications
None
Past Medical History
Term birth, BW 6-14, healthy, breastfed
First 10 years - healthy, rare OM, no wheezing, no asthma
First grade - learning disability - IEP. Then, homeschooled for 2nd and 3rd grade
12/2013 - . Torus fracture right radius
2013 & 2014 Seen by ----------
2013 & 2014 - Anxiety, abdominal pain (AM & after lunch), gassiness, constipation & diarrhea
2013- Missed 30 days of school
Surgical History
Denies Past Surgical History
Family History
Father: alive No GI problems
Mother: alive No GI problems
Siblings: No GI illness
3 brother(s) , 1 sister(s) .
Possible GERD in the family. No known inflammatory bowel disease.
Social History
Lives With: Parents, and Siblings.
Language: English.
Country of Birth: U.S.
Pediatric Home safety measures: has smoke detector.
Tobacco Exposure: No.
Animal Exposures: no pets in the home.
Allergies
N.K.D.A.
Hospitalization/Major Diagnostic Procedure
Denies Past Hospitalization
Review of Systems
CC basic:
Sick contacts none. Brought by mother.
Reason for Appointment
1. pediactic Evaluation
History of Present Illness
Depression Screening:
PHQ-9 Thoughts that you would be better off dead, or of hurting yourself in some way Not at all, Total Score 10, Intepretation Moderate Depression.
Pediatric Mood :
Parents primary concern: Possible anxiety and abdominal pain. Mother wants to know more about why Morgan has abdominal pain. Missed school because of stomach problems - dx irritable bowel, or may have other issues. Diet is good, constipation. Goes to the BR a lot, but c/o constipation & diarrhea. Parental report on General Mood: She is not getting the right help for reading. She has not been diagnosed with dyslexia, but mother has dyslexia, and would like a multisensory approach. . School issues: LD - dyslexic, in resource. WISC V. Problems: Stomach pain before school, then the night before. Mother would like to know if there is a physical reason for the problems. She has vomited twice at school on one day. Normally, her tummy pain starts in the morning or after lunch. Pain is better is she eats fruit smoothies and green smoothies. Worse with school foods w/ whole wheat. She has excess burping, gas. No bloating. Sometimes it is better after going to the bathroom Sometimes is shopping, and will beg to go home with stomach pain. Mid to upper.
Sick:
c/o concerns about Prior evaluation 3/17/2014 -Child was evaluated 2 months prior diagnosed with, fluctuating constipation/diarrhea abdominal pain bloating gassiness improved with defecation. Recommendation increase fiber increased fluid. Patient has been instituting fiber fluid without significant improvement in abdominal pain and bloating. Assessment - Anxiety from learning disability; request pediatric psych eval potential treatment of anxiety.
Vital Signs
Pain scale 0, Wt 55.0 lbs, Ht 50.87 in, BMI Percentile 12.42, BMI 14.94, BP 120/72, Temp 97.7, HR 109, SaO2 97, Ht Percentile 3.98, Wt Percentile 2.19.
Examination
CC Pediatric Exam:
GENERAL APPEARANCE: Very petite, alert, quiet and pleasant girl who is cooperative with the exam. SKIN: no rashes, no skin lesions. HEAD: normocephalic. EYES: normal, sclera/conjunctiva clear. EARS: TMs: pearly gray, with good light reflection. NOSE: nares patent and clear, mucosa normal. ORAL CAVITY: moist mucous membranes, tonsils normal, pharynx without erythema or exudate. NECK: supple, no lymphadenopathy. HEART: RRR, no murmurs. LUNGS: clear, equal breath sounds bilaterally. ABDOMEN: soft, nontender, no masses. EXTREMITIES: moving all extremities equally. NEUROLOGIC EXAM: non-focal. OTHER Interpretation of drawing: She comes from a well-anchored situation. Whatever the learning disabilities are, they create a appearance of being of being less mature in manner (more like an 8.5 year old girl). She has a certain sense of helplessness in terms of her ability to cope, but 'covers up' with a cheery outlook. She is generally accessible to people, is not overly anxious or agitated. She seems to have some low self esteem and feels powerless, but still feels secure in her world and connected to the people who love her. Second picture does show some signs of depression showing up, in that the dogs have sad faces, even though the big, center bear has a happy face.
Assessments
1. Abdominal pain, periumbilic - 789.05 (Primary)
2. Abdominal pain, chronic, generalized - 789.07
3. Flatulence, eructation, and gas pain - 787.3, etiology unclear. First thoughts: Constipation, Giardia, lactose intolerance and celiac disease can all cause these symptoms.
4. Learning disabilities - 315.2, reading level > 3 years delayed, math delay
5. School avoidance - V62.3, secondary to physiologic abdominal pain or functional abd pain vs. anxiety
Treatment
1. Abdominal pain, periumbilic
Start Zantac (Ranitidine) liquid, 15 mg/mL, 5 ml, orally, BID, 30 days, 300 ml, Refills 3
LAB: Stool- Giardia Antigen
LAB: Complete Metabolic Panel (Ordered for 03/31/2014) Normal Calcium, Serum 9.7
Glucose, Serum 106
BUN 15
Protein, Total, Serum 7.2
Albumin, Serum 4.4
Bilirubin, Total 0.4
Alkaline Phosphatase, S 375
AST (SGOT) 13
Potassium, Serum 4.1
Sodium, Serum 140
Chloride, Serum 109
Creatinine, Serum 0.61
ALT (SGPT) 22
Carbon Dioxide, Total 24
140 4.1 109 24 7 106 15 0.61 9.7 7.2 4.4 0.4 375 13 22 .
LAB: TSH (Ordered for 03/31/2014) Normal 1.94 TSH 1.94
LAB: Celiac Disease Panel (Ordered for 03/31/2014)
LAB: Sedimentation Rate-Westergren (Ordered for 03/31/2014) 1 Sedimentation Rate-Westergren 1
LAB: Stool- Occult Blood Negative OCCULT BLOOD, STOOL neg
LAB: H. PYLORI AG, STOOL
LAB: Cryotosporidium antigen
FUNCTIONAL ABDOMINAL PAIN
1. Regular meals, including breakfast, and good nutrition are important
Breakfast everyday, plus 5 servings of fruit or vegetables
Avoid soda, chocolate, chips, Cheetos and other non-nutritious foods
If drinking milk makes the abdominal pain worse, then try Lactaid Milk or soy milk.
Consider other medications and health foods that have been shown to help with abdominal pain;
Lactobacillus GG (Culturelle) or L. reuteri, which have been studied. Other Lactobacillus combinations may also be helpful, if the first two are not availble or are too expensive.
Medication - Cyproheptadine - has been helpful for some children
Peppermint capsules have helped some children.
Relaation techiques may be helpful
If your child is not improving, keep an abdominal pain and diet diary and return to clinic for further evaluation. Also, watch for signs of constipation, which is very common, and treat if present.
2. Abdominal pain, chronic, generalized
Will plan to check for common causes, and consider KUB for constipation. She was not distended today. GI referral if abdominal pain does not improve.
3. Learning disabilities
Recommend WISC IV to evaluate reasoning, short term memory, non-verbal learning, etc.
4. School avoidance
Previously, anxiety thought to be the source of abdominal pain and missed school. Patient denies being bullied, but learning disorders put her at risk. Anxiety is a common cause of abdominal pain; If medical evaluation does not find a cause for pain, and a trial of dairy-free/glutin free foods does not help, then a trial of an anti-anxiety medication would be a reasonable next step.
Preventive Medicine
CC sick: F/u for new symptoms, poor oral intake, increased crying or pain, difficulty breathing, high fevers, weakness, changes, or if worse.
Face to face time with patient > 50 minutes, Education of patient/caregiver and co-ordination of care comprised 50% of the face-to-face appointment time.
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