Level Help please

coder21

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What level would you choose? This is a nutrition follow up for Surgery. Thank you.

Patient with history of medically complicated obesity, currently undergoing a physician supervised weight loss program, is presenting for follow-up. Diet journals are consistent with improved eating habits and the patient is following an exercise program. She is doing really well with weight loss.

Reports moderate to severe fatigue of few years duration that interferes with optimal performance of daily activities. It is not alleviated by anything; but has improved since starting the weight loss program.
.eg

Current medication g3
Medication List Reconciled.
Atorvastatin 80 mg tablet take 1 tablet by Oral route 1 time per day at night.
Klor-Con M20 20 mEq tablet,ER particles/crystals take 1 tablet by Oral route with food 2 times per day.
Niaspan Extended-Release 1,000 mg tablet extended release 24 hr take 1 tablet (1,000 mg) by oral route once daily at bedtime after a low-fat snack.
Celebrex 200 mg capsule 1 capsule by Oral route 2 times per day.
Hydrochlorothiazide 25 mg tablet 1 tablet by Oral route 1 time per day.
Allopurinol 100 mg tablet 1 tablet by Oral route 1 time per day.
Paxil 30 mg tablet take 1 tablet by Oral route 1 time per day.
Lisinopril 20 mg tablet 1 tablet by Oral route 1 time per day.
Plavix 75 mg tablet 1 tablet by Oral route 1 time per day.
Metformin 500 mg tablet extended release 24 hr take 2 tablets (1,000 mg) by oral route once daily with the evening meal.
Nitrostat 0.4 mg tablet, sublingual 1 tab by Sublingual route . . for Chest Pain. Every 5 minutes if needed. If 3rd dose seek help.
Protonix 40 mg tablet,delayed release (DR/EC) take 1 tablet by Oral route 2 times per day.
Test Strips ///// Strip 2 times per day dx 250.00, FREE STYLE LITE.
Potassium chloride 20 mEq tablet,ER particles/crystals 1 tablet by Oral route 1 time per day.
Osphena 60 mg tablet take 1 tablet (60 mg) by oral route once daily with food.
Magnesium oxide 400 mg tablet 1 tablet by Oral route 2 times per day.
Lancets - Needle 4 times per day Freestyle use as directed dx 790.29.
TraZODONE 50 mg tablet take 2 tablets (100 mg) by oral route once daily at bedtime.
Glucometer Device dx 790.29.eg

Past medical/surgical history g4
Reported:
Surgical / Procedural: Knee replacement.
Diagnoses:
Acute myocardial infarction
Hypertension.
Esophageal reflux (GERD).
Hyperlipidemia.
Obesity.
Type 2 diabetes mellitus.
Stroke syndrome.
Depression
Procedural:
? Complete colonoscopy 2002
Surgical:
? Tonsillectomy
? Thyroid surgery
? Shoulder surgeryeg

Personal history g5
Behavioral: Never a smoker.eg

Review of systems g16
Systemic: Feeling tired or poorly. No fever and no chills.
Otolaryngeal: No nasal passage blockage (stuffiness) -Congestion.
Cardiovascular: No chest pain or discomfort and no palpitations.
Pulmonary: No shortness of breath. No cough.
Gastrointestinal: No dysphagia and no heartburn. No nausea, no vomiting, no diarrhea, and no constipation.
Hematologic: Easy bleeding and a tendency for easy bruising.
Musculoskeletal: Limb pain.
Arthralgias. No soft tissue swelling. Stiffness localized to one or more joints.eg

Physical findings g8
Vital Signs:
Vital Signs/Measurements Value Date
Oral temperature 98 9/23/2015
RR 16 per min 9/23/2015
PR 70 bpm 9/23/2015
Blood pressure 130/80 mmHg 9/23/2015
Pain level by numeric rating scale 0 9/23/2015
Weight 246 lbs 9/23/2015
Body mass index 38.5 kg/m2 9/23/2015
Height 67 in 9/23/2015
Standard Measurements:
Standard Measurements: Value Date
Body surface area 2.3 9/23/2015
Laboratory Studies:
Pulmonary Tests: Value Date
Oxygen saturation 98% percent 9/23/2015
Standard Measurements:
Patient was observed to be obese.
General Appearance:
Alert.
Eyes:
General/bilateral:
Eyes: normal.
Abdomen:
Visual Inspection: The abdomen was normal on visual inspection and the abdomen was not distended.
Palpation: No ascites, the abdomen was soft, abdominal non-tender, and no abdominal mass was palpated.
Liver: The liver was not enlarged.
Neurological:
Oriented to time, place, and person.
Psychiatric:
Mood: The mood was not depressed and was not anxious.
Skin:
The skin showed no generalized erythema. No skin lesions.
Cardiovascular Disorder:
No lymphedema.
Gastrointestinal Disorder:
No hernia.
Orthopedic Disorder:
Backache.eg

Assessment g11
? Lethargy was observed
? Morbid obesity due to excess calories
Patient with medically complicated obesity despite multiple attempts of weight loss with conventional methods. The patient is a good candidate for bariatric surgery. The patient's fatigue has improved since the start of the program and the patient is compliant with the recommended lifestyle changes.eg

Allergies and Adverse Reactions g24
No Known Allergies.
Allergies Reviewed.eg

Plan g13
? Follow-up visit 1 month(s)
? Niaspan Extended-Release 1,000 mg tablet extended release 24 hr. take 1 tablet (1,000 mg) by oral route once daily at bedtime after a low-fat snack. Dispense: 90 tablet(s). Refill: 3. REASON: Course Complete
1) 1200 Calorie Diet
2) Exercise Program
.eg

Other g15
Barriers to care addressed: None identified.eg
 

coder21

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This is a new patient what level would you code? Thank you for your help.

Chief complaint g1
The Chief Complaint is: New Bariatric pt here to discuss surgery options & pt complains of fatiques.eg

Patient with a history of medically complicated obesity, presenting for weight loss surgery evaluation. Patient has failed multiple attempts of weight loss using conventional methods: dieting, exercising, and commercial weight loss programs. Current diet is consistent of high calorie count food rich in carbohydrates and fat and reports minimal exercise.

Reports moderate to severe fatigue of few years duration that interferes with optimal performance of daily activities. Fatigue has been worsening with weight regain. It is not alleviated by any factors.
.eg

Current medication g3
Medication List Reconciled.
Spironolactone 25 mg tablet 1 tablet by Oral route 1 time per day.
? No Known Current Medicationseg

Past medical/surgical history g4
PCOS.
Surgical:
? Orthopedic surgery hipeg

Personal history g5
Lives with parents.
Behavioral: Caffeine use. Never a smoker.
Work: Working full time.
Marital: Single.eg

Family history g7
Mental illness (not retardation)
Heart disease
Diabetes mellitus
Breast cancer.eg

Review of systems g16
Systemic: Feeling tired or poorly. No fever and no chills.
Head: No headache.
Neck: No swollen glands in the neck.
Eyes: No vision problems and no blurred vision.
Otolaryngeal: No nasal passage blockage (stuffiness) -Congestion, no snoring, and no sore throat.
Cardiovascular: No chest pain or discomfort and no palpitations.
Pulmonary: No shortness of breath. No cough.
Gastrointestinal: No dysphagia, no jaundice, no change in stool, no bright red blood per rectum, no fecal incontinence, and no polyphagia. No heartburn. No nausea, no vomiting, no diarrhea, and no constipation.
Genitourinary: No inguinal swelling and no increase in urinary frequency. No dysuria.
Endocrine: No polydipsia, no temperature intolerance, and no hot flashes.
Hematologic: No easy bleeding and no tendency for easy bruising.
Musculoskeletal: No muscle aches, no soft tissue stiffness -muscle stiffness, and no limb pain.
No arthralgias. Soft tissue swelling. No localized joint stiffness.
Neurological: No memory lapses or loss, no dizziness, and no sensory disturbances.
Psychological: No anxiety, no depression, and no sleep disturbances.
Skin: No pruritus and no rash.
Urinary System: Bladder incontinence was not demonstrated.eg

Physical findings g8
Vital Signs:
Vital Signs/Measurements Value Date
PR 74 bpm 9/04/2015
Blood pressure 135/93 mmHg 9/04/2015
Pain level by numeric rating scale 0 9/04/2015
Weight 282.6 lbs 9/04/2015
Body mass index 50.1 kg/m2 9/04/2015
Height 63 in 9/04/2015
Standard Measurements:
Standard Measurements: Value Date
Body surface area 2.4 9/04/2015
Laboratory Studies:
Pulmonary Tests: Value Date
Oxygen saturation 96% percent 9/04/2015
Standard Measurements:
Patient was observed to be obese.
General Appearance:
Alert.
Neck:
Neck: normal.
Trachea: The trachea showed no abnormalities.
Eyes:
General/bilateral:
Eyes: normal.
Lungs:
Respiration rhythm and depth was normal, the lungs were clear to auscultation, no wheezing was heard, no rhonchi were heard, and no rales/crackles were heard.
Cardiovascular:
Heart Rate And Rhythm: Heart rate and rhythm normal.
Heart Sounds: Heart sounds normal S1 & S2.
Murmurs: No murmurs were heard.
Carotid Arteries: The carotid arteries were normal.
Arterial Pulses: Arterial pulses were equal bilaterally and normal.
Abdomen:
Visual Inspection: The abdomen was normal on visual inspection and the abdomen was not distended.
Palpation: No ascites, the abdomen was soft, abdominal non-tender, and no abdominal mass was palpated.
Liver: The liver was not enlarged.
Neurological:
Oriented to time, place, and person.
Psychiatric:
Mood: The mood was not depressed and was not anxious.
Skin:
The skin showed no generalized erythema. No skin lesions.
Cardiovascular Disorder:
No lymphedema.
Gastrointestinal Disorder:
No hernia.eg

Assessment g11
? Fatigue
? Morbid obesity
Patient with medically complicated obesity despite multiple attempts of weight loss with conventional methods. Based on the NIH criteria, the patient is a good candidate for bariatric surgery. After discussing all the different types of procedures, the patient would like to proceed with a laparoscopic vertical sleeve gastrectomy or bypass.eg

Allergies and Adverse Reactions g24
No Known Allergies.
Allergies Reviewed.eg

Plan g13
? Polysomnography with four or more additional sleep parameters
? An upper GI series with barium swallow 09/18/2015 9:30AM HOSPITAL NOTHING TO EAT OR DRINK AFTER MIDNIGHT LJ
? Follow-up visit 5 month(s)
? Request consultation by specialist Consult Mental Health
? spironolactone 25 mg tablet. 1 tablet by Oral route 1 time per day. Dispense: 30 tab(s). Refill: 5. . Educational Material Given.. REASON: Unknown
1) High Fiber/Protein Diet Limited to 1200 calories per day
2) Exercise Program
3) 6 month follow up with Bariatrician
4) Psychiatric Evaluation
5) UGI
6) sleep study
.eg

Other g15
Barriers to care addressed: None identified.eg
 

thomas7331

True Blue
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I would classify the MDM as low on the follow up visit because the provider is documenting two established problems (obesity and fatigue), both improving, with moderate level of risk for two chronic problems and/or prescription drug management.

The new patient visit I would give a 99204 for a comprehensive history and exam and moderate MDM.
 

coder21

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Thank you for your time and response. It was very helpful. For the est. I was going back in fourth with a 99212 or 99213 but the provider had 99214.
 
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