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How would you code this?

maine4me

Guru
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174
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0
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
 

pineapplelvr

Networker
Messages
74
Location
Duluth
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If I were to code this for the facility I work for, I would do it as preventive with a POS for where they were (assited living, group home, etc). If they met all the components for an AWV we have done that in addition to it. Since there is no real cheif complaint, it's not looking like an E/M to me, especially if their chronic problems are stable, and since they did a hands on exam, it's not just an AWV.

that's my 2 cents anyways :)
 
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