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bamagirl060900

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Harvest, AL
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I wanted someone else's opinion on this progress note. Can this be billed out? My opinion is the three key conponents have not been met or exceeded to bill new patient E/M visit.:eek:

CC: NP
History: here to establish, leaving pediatrician office
Current Allergies: NKDA
Current Meds: Benadryl
Current Problems: No current problems
Exam:
Vitals: BP Systolic 122, BP Diastolic 76, Pulse: 78, Temperature 97.8
Weight 115, Height 5'5.5", BMI 18.84
General: grooming is normal; well developed, well nourished, well hydrated, no apparent distress, average body build
Eyes: PERRLA, EOMI, conj & sclerae normal; normal opthalmic exam, lids normal
ENT: oropharynx clear, external nose have no scar, lesion, mass, or deformity; nasal mucosa is normal; tympanic membranes and external auditor canals clear; hearing is grossly intact
Neck: supple, normal thyroid , no bruits
Lymphatic: no lymphadenopathy
Respiratory: clear to auscultation bilaterally; auscultation of lungs revealed no rales, rhonchi, or wheezes
Cardiovascular: regular rhythm and rate, no murmors, gallops, rubs, regular rhythm, no mumur, or rub
Gastronintestinal: soft/NT/ND/BS+; no HSM present; no masses
Genitourinary: testicular exam normal; no masses; penilie exam normal; no lesions
Extremities: no clubbing, cyanosis, or edema
Musculoskeletal:normal ROM and strength
Neurological: DTRs 2+ and symmetric bilaterally; nonfocal exam; craial nerves II-XII grossly intact; sensation is; normal motor exam revealed strength 5/5 throughout
Skin: no rashes or lesions
Psychiatric: normal mood and effect

Assessment:
1.) 706.1 Acne
2.) 780.79 Fatigue

Plan:
Orders
1.) 99205 - New patient level 5

Processed Medications:
None

Follow Up:
1.) As needed

Further
Will plan to do Hepatitis A vaccine in the near future.
 
It is most certainly not a level 5 anything.

You have a new patient with no chief complaint so it should be a well care code.

Laura, CPC, CEMC
 
I know the preventive codes are pretty vague but there is really limited history listed so I would personally feel more comfortable with the unlisted 99429 based on this note.

So I would bill 99429, dx V70.0 primary and then the other dxs listed.

This provider needs some education on leveling. Did the EMR level this? Or did he choose the level? This note looks very similar to the Praxis EMR one of my providers uses. He doesn't use the leveling function they offer, for a few reasons, so I have never seen what happens when you do.

Laura, CPC, CEMC
 
History

Before using the unlisted, I'd go back to the physician for some clarification. It's possible that he has obtained patient's old records and that would suffice for a history that would meet 99385. He should amend his note to reflect that history if appropriate.

Also check if you have a new patient questionaire that may have been completed. The physician should also sign and date this form as having been reviewed (and mention it in his dictated note).

One of my greatest frustrations is getting doctors to document the negatives that they ask about but don't bother recording.

F Tessa Bartels, CPC, CEMC
 
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