Kcronin1122
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Hi All,
I am really trying to put an effort into understanding coding E/M's. Can you please tell me if you think this is a level 3 or 4, and how you are determining the outcome. Thank you
I had the pleasure of seeing your patient, Liam, here in the CLINIC accompanied by his mother. Liam is a 5 year old who is referred for evaluation of a murmur.
Liam's murmur was first noted at a recent routine well-child examination. It had not previously been heard. Liam is very physically active, participating in recreational activities, and can keep up with his peers. He has not complained of any chest pain, shortness of breath, or palpitations. He has not had any syncope with exercise. Liam has a vigorous appetite and is gaining weight on a regular diet. He consumes a balanced diet and adequate hydration. Liam's mother does not have any cardiac concerns at today's visit. He wants to be a weatherman and loved the recent snow.
Medical records reviewed and pertinent details are included in this note.
Past Medical History
Liam has had no chronic medical issues.
Current Meds:
No current outpatient medications on file prior to encounter.
Allergies:
No Known Allergies
Family History:
There is no family history of congenital heart disease, arrhythmias, or unexplained sudden death.
Social History:
Liam lives at home with his mother. He attends preschool.
Review of systems:
Constitutional: No history of unexplained fever or weight loss.
Neuro: No history of seizures. No syncope.
HEENT: No vision problems or hearing loss.
Resp: No history of cough, wheezing, or recurrent chest infections. -Asthma
GI: No vomiting, diarrhea, or reflux
GU: Good urine output. No hematuria.
Musculoskeletal: No weakness or poor tone
Endocrine: No symptoms of excessive coldness or hotness. No hair loss.
The remaining 10 point review of systems is negative.
Physical Exam:
BP 92/54 (BP SITE: RIGHT ARM) Pulse 104 Resp 24 Ht 111.5 cm Wt 18.2 kg (40 lb 2 oz) SpO2 99% BMI 14.64 kg/m2
In general, Liam was well nourished, acyanotic, and in no distress. No dysmorphic features. The oropharynx is moist. There is no scleral icterus or jaundice. The lungs are clear bilaterally and there are no retractions or tachypnea. The chest is symmetric. The precordium was quiet with a regular rate and rhythm. The first and second heart sounds were normal with a physiologic split second heart sound. There was a grade 2/6 systolic vibratory murmur localized to left sternal border; louder when supine. Diastole was quiet. No rub or gallop. The abdomen was soft with the liver edge palpable just below the right costal margin. Normal bowel sounds. Extremities are warm, well-perfused, and without clubbing. There were 2+ bilateral femoral pulses without brachiofemoral delay. Tone is normal for age.
CURRENT DIAGNOSTIC TESTING (I have personally reviewed and interpreted these studies)
ECG:
Normal sinus rhythm. This was a normal ECG.
IMPRESSION
Liam is a 5 year old with:
1. Murmur consistent with a benign flow murmur frequently heard in children.
PLAN
Liam has a normal cardiac evaluation by exam and ECG. The murmur noted on exam is consistent with a benign flow murmur frequently heard in children. Given Liam's normal evaluation today, I do not need to see him routinely here in cardiology clinic. Of course should any concerns on yours or the family's arise, I would be more than happy to re-evaluate him. In the meantime, Liam has no restrictions from a cardiovascular standpoint regarding routine care or activity. SBE prophylaxis is not indicated per the AHA recommendations.
I am really trying to put an effort into understanding coding E/M's. Can you please tell me if you think this is a level 3 or 4, and how you are determining the outcome. Thank you
I had the pleasure of seeing your patient, Liam, here in the CLINIC accompanied by his mother. Liam is a 5 year old who is referred for evaluation of a murmur.
Liam's murmur was first noted at a recent routine well-child examination. It had not previously been heard. Liam is very physically active, participating in recreational activities, and can keep up with his peers. He has not complained of any chest pain, shortness of breath, or palpitations. He has not had any syncope with exercise. Liam has a vigorous appetite and is gaining weight on a regular diet. He consumes a balanced diet and adequate hydration. Liam's mother does not have any cardiac concerns at today's visit. He wants to be a weatherman and loved the recent snow.
Medical records reviewed and pertinent details are included in this note.
Past Medical History
Liam has had no chronic medical issues.
Current Meds:
No current outpatient medications on file prior to encounter.
Allergies:
No Known Allergies
Family History:
There is no family history of congenital heart disease, arrhythmias, or unexplained sudden death.
Social History:
Liam lives at home with his mother. He attends preschool.
Review of systems:
Constitutional: No history of unexplained fever or weight loss.
Neuro: No history of seizures. No syncope.
HEENT: No vision problems or hearing loss.
Resp: No history of cough, wheezing, or recurrent chest infections. -Asthma
GI: No vomiting, diarrhea, or reflux
GU: Good urine output. No hematuria.
Musculoskeletal: No weakness or poor tone
Endocrine: No symptoms of excessive coldness or hotness. No hair loss.
The remaining 10 point review of systems is negative.
Physical Exam:
BP 92/54 (BP SITE: RIGHT ARM) Pulse 104 Resp 24 Ht 111.5 cm Wt 18.2 kg (40 lb 2 oz) SpO2 99% BMI 14.64 kg/m2
In general, Liam was well nourished, acyanotic, and in no distress. No dysmorphic features. The oropharynx is moist. There is no scleral icterus or jaundice. The lungs are clear bilaterally and there are no retractions or tachypnea. The chest is symmetric. The precordium was quiet with a regular rate and rhythm. The first and second heart sounds were normal with a physiologic split second heart sound. There was a grade 2/6 systolic vibratory murmur localized to left sternal border; louder when supine. Diastole was quiet. No rub or gallop. The abdomen was soft with the liver edge palpable just below the right costal margin. Normal bowel sounds. Extremities are warm, well-perfused, and without clubbing. There were 2+ bilateral femoral pulses without brachiofemoral delay. Tone is normal for age.
CURRENT DIAGNOSTIC TESTING (I have personally reviewed and interpreted these studies)
ECG:
Normal sinus rhythm. This was a normal ECG.
IMPRESSION
Liam is a 5 year old with:
1. Murmur consistent with a benign flow murmur frequently heard in children.
PLAN
Liam has a normal cardiac evaluation by exam and ECG. The murmur noted on exam is consistent with a benign flow murmur frequently heard in children. Given Liam's normal evaluation today, I do not need to see him routinely here in cardiology clinic. Of course should any concerns on yours or the family's arise, I would be more than happy to re-evaluate him. In the meantime, Liam has no restrictions from a cardiovascular standpoint regarding routine care or activity. SBE prophylaxis is not indicated per the AHA recommendations.