Our family physicians perform physical examinatons for patients who reside in a local nursing facility, these are required by the facility. Most of the patients have mental disabilities. The following is an example. Currently, our physicians bill this as an established E/M visits with the problem diagnoses listed. This visit was coded as a 99214 by out doctor.
I am curious how others would code this, and if it would be possibile to bill these visits as Medicare Annual Well Visit, for those patients with Medicare coverage. I realize all components of the AWV would have to be met.
Assessment and Plan
Ambulatory Assessment/Plan:
Assessment/Plan:
318.1 SEVERE MENTAL RETARDAT
299.00 AUTISTIC DISORDER, CURRENT OR ACTIVE STATE
389.9 Congenital hearing disorder (deaf)
300.3 Obsessive compulsive personality disorder
V77.1 Screening for Diabetes
V77.91 Screening for Lipoid Disorders
V77.0 Screening for Thyroid Disorder
Additional Plan Details:
check fasting labs - cbc with diff, cmp, lipid panel, tsh
flu vaccine and tdap given
physical performed for lifepath
reviewed lifetime med summary and meds.
f/u in 6m or prn
HPI
HPI
Nursing Chief Complaint: Lifepath PE
Physician: []
Vitals:
Height 65 in / 165.10 cm
Weight 131 lbs / 59.420604 kg
BSA 1.65 m2
BMI 21.8 kg/m2
Temperature 96.4 F / 35.78 C - Tympanic
Pulse 80
Blood Pressure 106/60 Sitting, Left Arm
Personal Medical History
Personal medical history: Hx of: Anxiety - OCD - Dr. Pobre-So (psych), Other - MR, autism, b/l deaf
Surgical History
Past Surgical History: Hx of: Other - surgery on his b/l ears - for correction of deafness - failed surgery
Social History
Social history:
Marital Status: Single
Household members: lives at LIFEPATH
Occupation: works at the lifepath day program
Tobacco
Smoking History: Never smoker
Tobacco status: Quit date established
Current Tobacco use: No
Alcohol
Alcohol Intake: None
Substance Use
Substance use: Denies use
Problem List
-----
Past Medical/Surgical History
Chronic Problems:
AUTISTIC DISORDER, CURRENT OR ACTIVE STATE
SEVERE MENTAL RETARDAT
EXAM
*****
*****
General: No acute distress.
HEENT: Sclera nonicteric, b/l hearing aides, pharynx clear without exudate. +
Neck: Supple, no lymphadenopathy.
Lungs: Clear to auscultation bilaterally.
Heart: Regular rate and rhythm without murmurs or rubs.
Neuro: CN II-XII grossly intact without focal deficit.
Skin: warm, dry, no lesions/rashes
abd; soft, nontender, +bs
testicle exam normal - prostate normal, heme negative stool
I am curious how others would code this, and if it would be possibile to bill these visits as Medicare Annual Well Visit, for those patients with Medicare coverage. I realize all components of the AWV would have to be met.
Assessment and Plan
Ambulatory Assessment/Plan:
Assessment/Plan:
318.1 SEVERE MENTAL RETARDAT
299.00 AUTISTIC DISORDER, CURRENT OR ACTIVE STATE
389.9 Congenital hearing disorder (deaf)
300.3 Obsessive compulsive personality disorder
V77.1 Screening for Diabetes
V77.91 Screening for Lipoid Disorders
V77.0 Screening for Thyroid Disorder
Additional Plan Details:
check fasting labs - cbc with diff, cmp, lipid panel, tsh
flu vaccine and tdap given
physical performed for lifepath
reviewed lifetime med summary and meds.
f/u in 6m or prn
HPI
HPI
Nursing Chief Complaint: Lifepath PE
Physician: []
Vitals:
Height 65 in / 165.10 cm
Weight 131 lbs / 59.420604 kg
BSA 1.65 m2
BMI 21.8 kg/m2
Temperature 96.4 F / 35.78 C - Tympanic
Pulse 80
Blood Pressure 106/60 Sitting, Left Arm
Personal Medical History
Personal medical history: Hx of: Anxiety - OCD - Dr. Pobre-So (psych), Other - MR, autism, b/l deaf
Surgical History
Past Surgical History: Hx of: Other - surgery on his b/l ears - for correction of deafness - failed surgery
Social History
Social history:
Marital Status: Single
Household members: lives at LIFEPATH
Occupation: works at the lifepath day program
Tobacco
Smoking History: Never smoker
Tobacco status: Quit date established
Current Tobacco use: No
Alcohol
Alcohol Intake: None
Substance Use
Substance use: Denies use
Problem List
-----
Past Medical/Surgical History
Chronic Problems:
AUTISTIC DISORDER, CURRENT OR ACTIVE STATE
SEVERE MENTAL RETARDAT
EXAM
*****
*****
General: No acute distress.
HEENT: Sclera nonicteric, b/l hearing aides, pharynx clear without exudate. +
Neck: Supple, no lymphadenopathy.
Lungs: Clear to auscultation bilaterally.
Heart: Regular rate and rhythm without murmurs or rubs.
Neuro: CN II-XII grossly intact without focal deficit.
Skin: warm, dry, no lesions/rashes
abd; soft, nontender, +bs
testicle exam normal - prostate normal, heme negative stool
