Help with this pre-op clearance

perkins05

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Location
New Orleans
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Help this is coded wrong?

Back Pain *

Associated Diagnoses: Back pain; Degenerative disc disease; Preoperative Clearance

Visit Information
Visit type: Increase in symptoms.
Accompanied by: Spouse.
.

Chief Complaint
CHIEF COMPLAINT
back pain
preop clearance for cataract surgery

History of Present Illness
Exacerbating factors consist of movement. Relieving factors consist of ibuprofen didn't help.

Review of Systems
Constitutional: Negative except as documented in history of present illness.
Eye: Negative.
Ear/Nose/Mouth/Throat: Negative.
Respiratory: Negative.
Cardiovascular: Negative.
Gastrointestinal: Negative.
Genitourinary: Negative.
Hematology/Lymphatics: Negative.
Endocrine: Negative.
Immunologic: Negative.
Musculoskeletal: Back pain.
Integumentary: Negative.
Neurologic: Negative.
Psychiatric: Negative.
All other systems are negative

Health Status
Allergies: .

No active allergies have been recorded.

Problem list: .
All Problems
arthropathy neck/hands
chronic neck pain
HIP PAIN
Hyperlipidemia, mixed 272
Hypertension
lumbar radiculopathy/DJD
Menopause 627.2
right ear pain
tachycardia
Unspecified Essential Hypertension / ICD-9-CM 401.9
Pure Hypercholesterolemia / ICD-9-CM 272.0
Routine General Medical Examination at a Health Care Facility / ICD-9-CM V70.0
Unspecified Chest Pain / ICD-9-CM 786.50
Insomnia, Unspecified / ICD-9-CM 780.52
Allergic Rhinitis, Cause Unspecified / ICD-9-CM 477.9
Pain in Joint, Site Unspecified / ICD-9-CM 719.40
Arthropathy Unspecified, Involving Other Unspecified Sites / ICD-9-CM 716.98
Osteoarthrosis, Unspecified Whether Generalized or Localized, Involving Hand / ICD-9-CM 715.94
Need for Prophylactic Vaccination and Inoculation Against Other Viral Diseases / ICD-9-CM V04.8
Sebaceous Cyst / ICD-9-CM 706.2
Tietze's Disease / ICD-9-CM 733.6
Benign Essential Hypertension / ICD-9-CM 401.1
Esophageal Reflux / ICD-9-CM 530.81
Unspecified Viral Infection in Conditions Classified Elsewhere and of Unspecified Site / ICD-9-CM 079.99
Spasm of Muscle / ICD-9-CM 728.85
Tachycardia, Unspecified / ICD-9-CM 785.0
Symptomatic Menopausal or Female Climacteric States / ICD-9-CM 627.2
Other Malaise and Fatigue / ICD-9-CM 780.79
Other Specified Anemias / ICD-9-CM 285.8
Anemia, Unspecified / ICD-9-CM 285.9
DYSURIA / ICD-9-CM 788.1
Otalgia, Unspecified / ICD-9-CM 388.70
Acute Swimmers' Ear / ICD-9-CM 380.12
Brachial Neuritis or Radiculitis Nos / ICD-9-CM 723.4
Pure Hyperglyceridemia / ICD-9-CM 272.1
Reflux Esophagitis / ICD-9-CM 530.11
Thoracic or Lumbosacral Neuritis or Radiculitis, Unspecified / ICD-9-CM 724.4
Other Disorders of Bone and Cartilage / ICD-9-CM 733.99
Need for Prophylactic Vaccination Against Streptococcus Pneumoniae [pneumococcus] / ICD-9-CM V03.82
Need for Prophylactic Vaccination and Inoculation Against Streptococcus Pneumoniae [pneumococcus] and Influenza / ICD-9-CM V06.6
Other and Unspecified Adverse Effect of Drug, Medicinal and Biological Substance / ICD-9-CM 995.2
Need for Prophylactic Vaccination and Inoculation Against Influenza / ICD-9-CM V04.81
Urinary Tract Infection, Site Not Specified / ICD-9-CM 599.0
Pain in Limb / ICD-9-CM 729.5
Unspecified Menopausal and Postmenopausal Disorder / ICD-9-CM 627.9
EDEMA / ICD-9-CM 782.3
Malignant Essential Hypertension / ICD-9-CM 401.0
Long-Term (Current) Use of Other Medications / ICD-9-CM V58.69
Angioneurotic Edema, Not Elsewhere Classified / ICD-9-CM 995.1
Bronchitis, Not Specified as Acute or Chronic / ICD-9-CM 490
Predominant Disturbance of Emotions / ICD-9-CM 308.0
Memory Loss / ICD-9-CM 780.93
Other Abnormal Blood Chemistry / ICD-9-CM 790.6
Unspecified Gastritis and Gastroduodenitis, without Mention of Hemorrhage / ICD-9-CM 535.50
Shortness of Breath / ICD-9-CM 786.05
HEADACHE / ICD-9-CM 784.0
Cellulitis and Abscess of Upper Arm and Forearm / ICD-9-CM 682.3
Need for Prophylactic Vaccination and Inoculation Against Other Specified Disease / ICD-9-CM V05.8
Acute Sinusitis, Unspecified / ICD-9-CM 461.9
WHEEZING / ICD-9-CM 786.07
Contact Dermatitis and Other Eczema / ICD-9-CM 692
Unspecified Deficiency Anemia / ICD-9-CM 281.9
Insect Bite, Nonvenomous, of Foot and Toe(s), without Mention of Infection / ICD-9-CM 917.4
Insect Bite, Nonvenomous, of Hand(s) Except Finger(s) Alone, without Mention of Infection / ICD-9-CM 914.4
Obesity / ICD-9-CM 278.00 / Probable

Histories
Past Medical History: .
No active or resolved past medical history items have been selected or recorded.
Family History: .
No family history items have been selected or recorded.
Procedure history: .
No active procedure history items have been selected or recorded.
Social History
. No active social history items have been recorded.

Physical Examination
VS/Measurements
Vital Signs
Temperature Oral 98.2 DegF
Peripheral Pulse Rate 75 bpm
Respiratory Rate 18 br/min
Systolic Blood Pressure 119 mmHg
Diastolic Blood Pressure 71 mmHg
BP Site Right arm
, Measurements from flowsheet : Measurements
:confused: Height 62.00 in
Weight 160.00 lb
BSA 1.78
Body Mass Index 29.26 kg/m2
Ht/Wt Measurement Refused by Patient? No

General: Alert and oriented, No acute distress.
Eye: Pupils are equal, round and reactive to light, Extraocular movements are intact.
HENT: Tympanic membranes are clear.
Mouth: Within normal limits.
Throat: Within normal limits.
Neck: Supple, Non-tender.
Respiratory: Lungs are clear to auscultation.
Respirations: Are within normal limits.
Cardiovascular: Normal rate, No murmur.
Gastrointestinal: Soft, Non-tender, Non-distended.
Genitourinary: No costovertebral angle tenderness.
Lymphatics: No lymphadenopathy neck, axilla, groin.
Musculoskeletal: Normal range of motion, Normal strength.
Spine/torso exam: Lumbar ( Bilateral ).
Integumentary: Warm, Dry, Pink.
Feet: Normal by visual exam.
Neurologic: Alert, Oriented, Normal coordination.
Coordination: Within normal limits.
Psychiatric: Cooperative, Appropriate mood & affect, Normal judgment, Non-suicidal.

Impression and Plan
Diagnosis
Back pain (ICD9 724.5).
Degenerative disc disease (ICD9 722.6).
Diagnosis
Preoperative Clearance (ICD9 V72.84).


Doctor Coded
99214
96372
j1040
 
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