HKOFOID
Networker
I am trying to help my doctors understand what exactly it is that they are supposed to be doing during the annual wellness visits. One of my doctors dictated the chart note below and wants to bill 99215-25, G0438. I do not see any of the required elements in this chart note for the G0438. I was hoping I could get some feedback, so that I know I am not crazy as I have given the doctors all the information to what needs to be done in the visit. Maybe I am confused and I am just not seeing the elements in the chart note?
S: 68-year-old with history of HTN, osteopenia, elevated cholesterol, and vitamin D deficiency presents for comprehensive evaluation. She reports occasional sleep difficulty. Otherwise, doing well. More physically active this winter in AZ. She needs med refills. No other active complaints. Med sheet, problem sheet, chart reviewed and updated. Remainder of 12-point ROS unrevealing.
O: Healthy appearing, NAD, VSS. Weight stable. HEENT: Notable for a number of seborrheic lesions; otherwise, benign. NECK: Supple without thyroid enlargement. No JVD, bruits, or nodes. LUNGS: Clear throughout. CARDIAC: RR without MGR. Breasts are symmetric without mass. No axillary nodes. ABDOMEN: Soft, nontender. No masses, no organ enlargement. No bruits are heard. PELVIC: Normal appearing external genitalia without prolapse. Bimanual exam was deferred. RECTAL: Without mass. EXTREMITIES: No CC&E. Pulses equal and symmetric. Neurologically intact. SKIN: Benign. LAB: Shows improved lipid parameters. Recent DEXA scan showed slight improvement over 2008.
A: HTN, elevated cholesterol, osteopenia, and vitamin D deficiency all stable.
P: Continue present approach. Anticipatory guidance was given. Noted that her mammogram was benign. Recommended Zostavax again. Reviewed vitamin D replacement. New Rxs were written. Recheck p.r.n.
S: 68-year-old with history of HTN, osteopenia, elevated cholesterol, and vitamin D deficiency presents for comprehensive evaluation. She reports occasional sleep difficulty. Otherwise, doing well. More physically active this winter in AZ. She needs med refills. No other active complaints. Med sheet, problem sheet, chart reviewed and updated. Remainder of 12-point ROS unrevealing.
O: Healthy appearing, NAD, VSS. Weight stable. HEENT: Notable for a number of seborrheic lesions; otherwise, benign. NECK: Supple without thyroid enlargement. No JVD, bruits, or nodes. LUNGS: Clear throughout. CARDIAC: RR without MGR. Breasts are symmetric without mass. No axillary nodes. ABDOMEN: Soft, nontender. No masses, no organ enlargement. No bruits are heard. PELVIC: Normal appearing external genitalia without prolapse. Bimanual exam was deferred. RECTAL: Without mass. EXTREMITIES: No CC&E. Pulses equal and symmetric. Neurologically intact. SKIN: Benign. LAB: Shows improved lipid parameters. Recent DEXA scan showed slight improvement over 2008.
A: HTN, elevated cholesterol, osteopenia, and vitamin D deficiency all stable.
P: Continue present approach. Anticipatory guidance was given. Noted that her mammogram was benign. Recommended Zostavax again. Reviewed vitamin D replacement. New Rxs were written. Recheck p.r.n.
