I have a provider who wants to bill 99215 on her follow ups, but if there is no changes in PFSH and not treating all conditions except in her assessment/ plan … is that even valid ??
example:
HPI
81 yo female with history of OSA, CKD, Atrial Fibrillation, HTN/HLD, and ?COPD referred for evaluation.
See PRIOR 2015/16/17 Notes
03/22/2017-She states she feels ok. She still has the chronic cough and congestion but she states she has chronic bronchitis. She states that the she was on Doxycycline and broke out in to a rash on her chest and on her groin. She was seen by her primary and dermatology for the rashes. She is currently taking Gentamycin, but was unable to get her other prescriptions. She is being followed by her other specialists for rash.
5/17/17-Coughing less. Feeling pretty good. Using Advair and Spiriva daily. SOB seems stable.
8/15/17- She is doing well. she is doing well.
10/31/2017- She is about the same. PFT done. She is having knee surgery next month.
1/16/2018- She has been at rehab, She was at Villa Rehab, had the flu, viral infections. When she is walking with the rehab walker and noticed she is much more short of breath. She has not been able to use CPAP at the facility.
4/18/2018- She fell after going home and has struggled since then. She notes that she has had a productive cough since then. Has a cough that feels deep in her chest. Hoarse. Color is yellow and increased in amount.
5/9/18-Never received augmentin due to allergy with PCN. PMD gave her Bactrim. She is still coughing. Bringing up lots of yellow mucus. She has a rattle in her chest.
6/27/2018- She went to Simon Med for her CXR so we will call again for results. Has congestion and coughing. Has atypical stomach and chest discomfort, cleaned cabinets yesterday. States it may be her bladder or GERD, tried Nexium and water. Notes 'milk normally makes it go away." States she can not go to ER she has to go to bank.
10/17/18-Was hospitalized; S/P Chole now. Coughing, SOB, bringing up clear phelgm. CT Chest done at Simon Med
5/29/19 - Was at RCH during many missed appointments per patient. Had PFT 11/2018. She is not using CPAP. At rehab they would
9/4/19-She has been coughing for 4-6 weeks. She wakes up all the time coughing. She has been using nebulizer with minimal improvement.
9/25/19 - Patient is doing well. She finished antibiotics and is doing better, then returned and resumed with no change. ? Related to her CPAP machine.
Review of Systems
Constitutional: Positive for malaise/fatigue.
HENT: Positive for congestion.
Respiratory: Positive for cough, sputum production, shortness of breath and wheezing.
Cardiovascular: Negative for chest pain.
Gastrointestinal: Positive for heartburn (on nexium).
Neurological: Negative for headaches
Psychiatric/Behavioral: The patient has insomnia.
Physical Exam
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished.
HENT:
Head: Normocephalic and atraumatic.
Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses.
Pulmonary/Chest: Effort normal and breath sounds normal.
Abdominal: Soft. Bowel sounds are normal.
Musculoskeletal: Normal range of motion.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm and dry. Capillary refill takes less than 2 seconds.
Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment and thought content normal.
ASSESSMENT:
Hypersensitivity Pneumonitis
-with acute exacerbation; start prednisone taper.
-PFT a year 9/2018
-Self D/c'd Prednisone, has not had flu x 6 months
-Needs PFT annually q6 months, 9/2019 TLC 78%, 2018 78%
-HP panel negative .
-ose follow up
-PFT 11/2018 TLC 78%, DLCO 44%
-CXR 9/2019 reviewed, no gross infiltrates noted
Severe OSA
-AHI of 48.6 on sleep study.
-needs CPAP of 9 with face mask, delivered tomorrow
-run SIM card with each visit
-Repeated sleep study: done needs CPAP 16, only tolerates 14; needs to use. Needs new mask.
Aspergillus on bronchoscopy, s/p treatment.
-IGE normal at 64 but slight increase since 9/2016 to 43. Repeat IGE level now 39.
-Normal IGE levels, AST/ALT on tx of aspergillus
-Holding Itraconazole and Prednsione, s/p 100mg po daily and prednisone 10 mg po dailyX 3 months. -Not taking ENELBREX
-repeat cultures on bronch negative.
Asthma/Chronic bronchitis- non smoker, significant second hand smoker exposure
-does not have evidence of obstruction on PFT.
-acute exacerbation start z--pack and prednisone.
-Chronic mucus production, on Mucinex
-Never Smoker
-On Advair/Spiriva/ProAir and Duonebs PRN
-Continue singulair once daily
-Because of sotalol use she can not take daily Azithro
Allergic Rhinitis- on certrizine,continue singulair, Flonase
Reduced diffusion capacity
-DLVA now 68%, was 44%
Mild pulmonary hypertension- likely multifactorial 2/2 lung, heart disease.
-RA and RV normal size.
-Continue optimization of her underlying lung and heart disease.
-Restart CPAP at 14.
-Needs to use consistentl
-Used phen phen only for a few weeks.
GERD on PPI (nexium)
Hoarseness for years, no airway inspection and patients mother had throat cancer, bronchoscopy without lesions.
PLAN:
Start z-pack and prednisone taper.
Order CPAP 9 per titration with face mask --> new machine to arrive tomorrow
Needs PFT NOW 6-12 months
Using Flonase.
Continue nebulizer as needed --> encouraged use
Continue advair and spiriva.
Use Singulair once daily
Has generic Zyrtec
Has Flonase nasal spray
Optimized for surgery from a pulmonary standpoint
example:
HPI
81 yo female with history of OSA, CKD, Atrial Fibrillation, HTN/HLD, and ?COPD referred for evaluation.
See PRIOR 2015/16/17 Notes
03/22/2017-She states she feels ok. She still has the chronic cough and congestion but she states she has chronic bronchitis. She states that the she was on Doxycycline and broke out in to a rash on her chest and on her groin. She was seen by her primary and dermatology for the rashes. She is currently taking Gentamycin, but was unable to get her other prescriptions. She is being followed by her other specialists for rash.
5/17/17-Coughing less. Feeling pretty good. Using Advair and Spiriva daily. SOB seems stable.
8/15/17- She is doing well. she is doing well.
10/31/2017- She is about the same. PFT done. She is having knee surgery next month.
1/16/2018- She has been at rehab, She was at Villa Rehab, had the flu, viral infections. When she is walking with the rehab walker and noticed she is much more short of breath. She has not been able to use CPAP at the facility.
4/18/2018- She fell after going home and has struggled since then. She notes that she has had a productive cough since then. Has a cough that feels deep in her chest. Hoarse. Color is yellow and increased in amount.
5/9/18-Never received augmentin due to allergy with PCN. PMD gave her Bactrim. She is still coughing. Bringing up lots of yellow mucus. She has a rattle in her chest.
6/27/2018- She went to Simon Med for her CXR so we will call again for results. Has congestion and coughing. Has atypical stomach and chest discomfort, cleaned cabinets yesterday. States it may be her bladder or GERD, tried Nexium and water. Notes 'milk normally makes it go away." States she can not go to ER she has to go to bank.
10/17/18-Was hospitalized; S/P Chole now. Coughing, SOB, bringing up clear phelgm. CT Chest done at Simon Med
5/29/19 - Was at RCH during many missed appointments per patient. Had PFT 11/2018. She is not using CPAP. At rehab they would
9/4/19-She has been coughing for 4-6 weeks. She wakes up all the time coughing. She has been using nebulizer with minimal improvement.
9/25/19 - Patient is doing well. She finished antibiotics and is doing better, then returned and resumed with no change. ? Related to her CPAP machine.
Review of Systems
Constitutional: Positive for malaise/fatigue.
HENT: Positive for congestion.
Respiratory: Positive for cough, sputum production, shortness of breath and wheezing.
Cardiovascular: Negative for chest pain.
Gastrointestinal: Positive for heartburn (on nexium).
Neurological: Negative for headaches
Psychiatric/Behavioral: The patient has insomnia.
Physical Exam
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished.
HENT:
Head: Normocephalic and atraumatic.
Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses.
Pulmonary/Chest: Effort normal and breath sounds normal.
Abdominal: Soft. Bowel sounds are normal.
Musculoskeletal: Normal range of motion.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm and dry. Capillary refill takes less than 2 seconds.
Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment and thought content normal.
ASSESSMENT:
Hypersensitivity Pneumonitis
-with acute exacerbation; start prednisone taper.
-PFT a year 9/2018
-Self D/c'd Prednisone, has not had flu x 6 months
-Needs PFT annually q6 months, 9/2019 TLC 78%, 2018 78%
-HP panel negative .
-ose follow up
-PFT 11/2018 TLC 78%, DLCO 44%
-CXR 9/2019 reviewed, no gross infiltrates noted
Severe OSA
-AHI of 48.6 on sleep study.
-needs CPAP of 9 with face mask, delivered tomorrow
-run SIM card with each visit
-Repeated sleep study: done needs CPAP 16, only tolerates 14; needs to use. Needs new mask.
Aspergillus on bronchoscopy, s/p treatment.
-IGE normal at 64 but slight increase since 9/2016 to 43. Repeat IGE level now 39.
-Normal IGE levels, AST/ALT on tx of aspergillus
-Holding Itraconazole and Prednsione, s/p 100mg po daily and prednisone 10 mg po dailyX 3 months. -Not taking ENELBREX
-repeat cultures on bronch negative.
Asthma/Chronic bronchitis- non smoker, significant second hand smoker exposure
-does not have evidence of obstruction on PFT.
-acute exacerbation start z--pack and prednisone.
-Chronic mucus production, on Mucinex
-Never Smoker
-On Advair/Spiriva/ProAir and Duonebs PRN
-Continue singulair once daily
-Because of sotalol use she can not take daily Azithro
Allergic Rhinitis- on certrizine,continue singulair, Flonase
Reduced diffusion capacity
-DLVA now 68%, was 44%
Mild pulmonary hypertension- likely multifactorial 2/2 lung, heart disease.
-RA and RV normal size.
-Continue optimization of her underlying lung and heart disease.
-Restart CPAP at 14.
-Needs to use consistentl
-Used phen phen only for a few weeks.
GERD on PPI (nexium)
Hoarseness for years, no airway inspection and patients mother had throat cancer, bronchoscopy without lesions.
PLAN:
Start z-pack and prednisone taper.
Order CPAP 9 per titration with face mask --> new machine to arrive tomorrow
Needs PFT NOW 6-12 months
Using Flonase.
Continue nebulizer as needed --> encouraged use
Continue advair and spiriva.
Use Singulair once daily
Has generic Zyrtec
Has Flonase nasal spray
Optimized for surgery from a pulmonary standpoint