CPT 99396 25
This is what has been accepted, but they still say I am missing one or more codes. Does anyone besides myself find these things more than chalenging? Here is the note:
Chief Complaint: Annual exam
Pt here for her annual exam, would like to have Pellets Implanted.
History Of Present Illness:
This patient requests hormone pellet insert. Indications reviewed and concems about ability to achieve physiologic levels, avoid peaks and troughs, and safety concerns such as bothersome side effects of testosterone have been reviewed.
In this case the concern is of premature surgical menopause and inability to achieve adequate response from more standard forms of hormone therapy.
The skin was prepped with betadine and 5 cc of xylocaine placed on anterior abdominal wall. Small nick in skin made with scalpel, the skin gently undermined. Subcutaneous pellet(s) were then inserted into the skin.
Gentle pressure and a bandaid were applied and patient Instructed to keep the area dean and dry, to apply direct pressure if any bleeding occurs. To call if any concerns.
The patient is a 44 year old female gravida para.
Her general health issues include Ovarian Cancer.
Social history reviewed. Has had marital counseling recently; husband getting testosterone injections. Very stressed about marriage, finances, spouse with health Issues he's not addressing and they run an autodealership so economy has hit very hard
Past Surgical History: Abdominal hysterectomy with bilateral oopherectomy.
Estradiol 50 mg pellet
Spironolactone Oral Tablet 100 mg Testosterone 100 mg pellet
Valtrex Oral Tablet 1 g
Wellbutrin SR Oral Tablet Sustained Release 100 mg
Revievtf of Systems:
Constitutional - Denies : body aches, night sweats
HENT - Denies : headaches, dental problems, neck stiffness, oral ulcers
Breasts - Denies : lumps, tenderness, swelling, nipple discharge, abnormal changes In breast size
Cardiovascular - Denies : chest pain, syncope, dyspnea on exertion, lower extremity edema, varicosities
Respiratory - Denies : shortness of breath, cough
Gastrointestinal - Denies : nausea, vomiting, diarrhea, constipation, abdominal pain, blood In stools, excessive flatulence
Genitourinary - Denies : urgency, frequency, dysuria, hematuria. Incontinence, decreased libido, dyspareunia, genital sores. Irregular menses, menorrhagia, metrorrhagia, vaginal discharge, significant PMS.
Integumentary - Denies : rash, changes to existing skin lesions or moles, hirsutism, Thinning hair-alopecia. Bothersome facial hair - age appropriate
Neurologic - Denies : muscular weakness. Incoordination, tingling or numbness, difficulty concentrating, snoring
Musculoskeletal - Denies : joint pain, joint swelling, muscle pain, muscle cramps, back pain
Endocrine - Denies : polyuria, polydipsia, cold intolerance, heat intolerance, central obesity
Psycliiatric - Denies : anxiety, depression, feeling confused, difficulty sleeping
Heme-Lymph - Denies : easy bleeding, easy bruising, lymph node enlargement or tenderness
Allergic-Immunologic - Admits : seasonal allergies
BMI is 24.14 kg/m2 .
BP 100/70 WT 178 lbs 0oz HT 6' 0"
Constitutional - Appearance : well-nourished, well developed, alert, in no acute distress
Eyes - Conjunctiva/Eyelids : Normal appearance. Sclera : Normal appearacne.
HENT- Head and Face : Pleasant, symmetrical, normal fades. No hirsutism. Ears : Extemal ears within normal limits. Hearing grossly Intact.
Neck - Inspection/Palpation : normal appearance, no masses or tenderness. Thyroid : gland size normal, nontender, no nodules or masses present on palpation
Chest - Respiratory Effort: breathing unlabored.
Breasts - Inspection of Breasts : breasts symmetrical, no skin changes, no discharge present, no skin retraction present. Palpation of Breasts and Axillae : no masses present on palpation, no breast tenderness. Axillary Lymph Nodes: no lymphadenopathy present
Gastrointestinal - Abdominal Examination : abdomen nontender to palpation, tone normal without rigidity or guarding, no masses present, umbilicus without lesions well healed scar from surgery. Liver and spleen : no hepatomegaly present, liver nontender to palpation. Hernias : no hernias present
Genitourinary - External Genitalia : normal appearance for age, no discharge present, no tenderness present, no inflammatory lesions present. Vagina: normal vaginal vault without central or paravaginal defects, no discharge present, no inflammatory lesions present, no masses present. Bladder : nontender to palpation. Cervix: Absent. Uterus: Absent. Adnexa : no adnexal tenderness present, no adnexal masses present No nodularity. Perineum : perineum within normal limits, no evidence of trauma, no rashes or skin lesions present. Anus: anus within normal limits, Rectal: normal sphincter tone, no rectal masses present. Stool/Hemoccult Testing: Office testing not recommended-ACS guidelines normally followed.
Lymphatic - Lymph Nodes : no other lymphadenopathy present
Musculoskeletal - Lumbosacral Spine : No visible defects or deformities. Pelvis : No visible defects or deformities. Right.Upper Extremity: Inspection/Palpation: Appears normal. Motor Function: Appears normal. Left Upper Extremity: Inspection/Palpation: Appears normal. Digits and Nails: Appear normal. Range of Motion: Appears normal. Motor Function: Appears normal. Right Lower Extremity: Inspection/Palpation: Appears normal.Range of Motion: Appears normal Left Lower Extremity: Range of Motion : Appears normal
Skin - General Inspection : no rashes present, no lesions present, no areas of discoloration.
Scalp : no rashes present, no lesions present, normal hair pattern present Body Hair: general body hair distribution normal female for age. Pubic Hair: Normal for age
Neurologic/ Psychiatric - Mental Status : altert, pleasant, and articulate. Coordination: coordination normal. Gait and Station : normal gait and station
Assessment: Premature menopause. Premature Ovarian Failure/Menopause. Annual/Gynecological Exam Routine. Herpes Simplex, prior workup revealed type I genital lesions. Gets occasionally, had called for valtrex script.
Orders: Mammogram, screening bilateral
SUBCUTANEOUS HORMONE PELLET IMPLANTATION OF ESTRADIOL
Medications: Estradiol 50 mg pellet 50 mg
Testosterone 100 mg pellet
Instructions: Mammography recommended annually by ACOG and ACS for normal risk women over 40. Any patient concerns discussed.
Disposition: Call or RTC if symptoms worsen or persist.