Wiki Level for presciption refill?

[veloso]

Hi All,
What is the appropriate Level of Service for a RX. Refill? because I have a provider who bill it as 99213 with notes as follows:
HPI:
54 yo male presents here for pain meds refills for arthritic low back pain. Reports doing fine with new meds including metformin and crestor, but havine 2 days of dark stools after starting on metformin and then normal stools--he refuses DRE for guaiac testing--states he has appointment with GI.
GENERAL ROS
Cardiovascular Negative for:, chest pain, palpitations, edema. General Negative for:, fever, chills, fatigue, loss of appetite, weight change. Respiratory Negative for:, cough, shortness of breath, breathing problems.

General Examination
GENERAL APPEARANCE: well nourished and hydrated, NAD, comfortable, alert, walks with a cane. EXTREMITIES: no clubbing, no edema, no cyanosis.

Tx:
Hypertension
Continue Baby Aspirin Tablet Chewable, 81 MG, Orally, 1 tablet, Once a day
Continue Amlodipine Besylate Tablet, 5 MG, Orally, 1 tablet, Once a day
Continue Metoprolol Succinate Tablet Extended Release 24 Hour, 100 mg, Orally, 1 tablet, Once a day
BP is under good control.
ARTHROPATHY NOS-MULT
Continue Oxycodone-Acetaminophen Tablet, 10-325 MG, Orally, 60, 1 tablet as needed, twice a day, 30 days, Refills 0
Reviewed pain contract
Diabetes mellitus type 2
Continue Metformin HCl Tablet, 850 MG, Orally, 1 tablet with a meal, Once a day
HgbA1C from 7/20/11 was 6.5% and, he has gained weight even with less meals--pt agreed to trial Metformin with risk/benefits discussed.
FLATUL/ERUCTAT/GAS PAIN
Continue Pancrelipase, as directed, twice a day with meals
Continue Simethicone Tablet Chewable, 125 MG, Orally, 1 tablet as needed, Four times a day after meals and at bedtime
Continue Ranitidine HCl Tablet, 150 MG, Orally, 1 tablet, Twice a day
Continue Colace Capsule, 100 mg, Orally, 1 capsule as needed, Four times a day
Hyperlipidemia NOS
Continue Crestor Tablet, 10 mg, Orally, 1 tablet, Once a day
pt agreed to trial statin with risk/benefits discussed--f/u in 4 weeks for LFT--informed pt of significant side effects/warnings with statin use
Tobacco use disorder
Continue Nicotine Polacrilex Gum, 4 MG, Mouth/Throat, 1 piece for 30 minutes as needed, 24 time(s) a day
smoking 1PPD since age 23--now smokes 10 cigarettes/day
Chronic pancreatitis NOS
s/p multiple (> 4 times) admissions for acute exacerbation of chronic alcoholic pancreatitis after binge drinking-- pt advised against alcohol consumption to prevent flare-ups
Portal vein thrombosis
He had been f/u with anticoag clinic until 2 months ago, did sonogram/CT/MRI of liver, and was told his liver infarction has resolved--Dr. Adler took him off anticoagulants (he was on Lovenox, f/b coumadin, then Aristra injections)--medical records requested for this medical condition--will see GI in 4 weeks
Others
Continue Ambien Tablet, 10 mg, Orally, 30, 1 tablet at bedtime, Once a day, 30 days, Refills 0
Procedures:
Immunizations:

Diagnostic Imaging:
Lab Reports:
Preventive Medicine:
Next Appointment:
4 Weeks (f/u, fasting labs)


Pls.needs any INPUT.

Thanks.

 

[mdoyle53]

the note meets the qualifications of a 99213. The bigger question which will become a major one soon is the medical necessity of the visit. Because of the basic information but the severity of all the scripts the patient has, if I was a provider the argument would be: see the patient to ensure there is not an issue or contraindication between drugs, etc.

Therefore I would push to bill this as the provider wants

 

[veloso]

Thanks a lot,Contributor...