KristieStokesCPC
Expert
I am still having the worst time with Medicare to get a physical paid for. I know they will absolutely not pay for diagnosis code V70.0 (annual exam). I have copied his note below for help. I'm not sure that I can use V15.89 to get it paid...
CC:
Mr. XX is a 69-year-old male. He is here for an annual exam.
HPI:
Patient complains of annual exam. His last physical exam was 4 years ago. He underwent colonoscopy 1979 years ago with normal results. He's had vision screening done 10 years ago and this was normal.
Smoking Status: Nonsmoker
ROS:
CONSTITUTIONAL: Negative for chills, fatigue, fever, and weight change.
EYES: Negative for blurred vision, eye pain, and photophobia.
E/N/T: Negative for hearing problems, E/N/T pain, congestion, rhinorrhea, epistaxis, hoarseness, and dental problems.
CARDIOVASCULAR: Negative for chest pain, palpitations, tachycardia, orthopnea, and edema.
RESPIRATORY: Negative for cough, dyspnea, and hemoptysis.
GASTROINTESTINAL: Negative for abdominal pain, heartburn, constipation, diarrhea, and stool changes.
MUSCULOSKELETAL: Negative for arthralgias, back pain, and myalgias.
NEUROLOGICAL: Negative for dizziness, headaches, paresthesias, and weakness.
HEMATOLOGIC/LYMPHATIC: Negative for easy bruising, bleeding, and lymphadenopathy.
ENDOCRINE: Negative for hair loss, heat/cold intolerance, polydipsia, and polyphagia.
PSYCHIATRIC: Negative for anxiety, depression, and sleep disturbances.
Immunizations:
None
Allergies:
No Known Drug Allergies.
Current Medications:
Valtrex 500mg Tablet take one tablet qd
OBJECTIVE:
Vitals:
Current: 2/26/2008 8:56:21 AM
Ht: 67 inches; Wt: 195 lbs; BMI: 30.54
T: 98 F (oral); BP: 138/77 mm Hg (left arm, sitting); P: 92 bpm (left arm (BP Cuff), sitting); R: 16 bpm
VA: 20/50 OD, 20/25 OS (without correction)
Exams:
GENERAL: well developed, well nourished, in no apparent distress
EYES: lids and conjunctiva are normal; PERRLA; EOMI; fundoscopic exam reveals bilateral loss of red reflex, left > right;
E/N/T: normal external ears and nose;; Ears: left TM is normal; left EAC is normal; right EAC is occluded by cerumen; Hearing Screen: Able to hear fingers rubbed together with both ears; Nose: normal nasal mucosa, septum, turbinates, and sinuses; Lips/Teeth/Gums: gingival edema; white ulcer right lower outer gum with dental caries right posterior molar into gum line Oropharynx: normal mucosa, palate, and posterior pharynx;
NECK: Neck is supple with full range of motion; thyroid is normal to palpation;
RESPIRATORY: normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs;
CARDIOVASCULAR: normal rate; regular rhythm; no murmurs carotids: 2+ amplitude, no bruits; 2+ pedal pulses; no edema;
GASTROINTESTINAL: normal bowel sounds; no masses or tenderness; no organomegaly rectal exam: normal tone; nontender, guaiac negative stool; guaiac negative stool;
GENITOURINARY: prostate: no nodules, tenderness, or enlargement;
LYMPHATIC: no enlargement of cervical nodes; right submandibular node;
MUSCULOSKELETAL: digits/nails: no clubbing, cyanosis, or evidence of ischemia or infection; normal gait; grossly normal tone and muscle strength; full, painless range of motion of all major muscle groups and joints no masses, effusions, misalignment, crepitus, or tenderness in major joints;
NEUROLOGIC: cranial nerves: 2-12 grossly intact; normal DTR's elicited in biceps, triceps, supinator, knee, and ankle jerk; sensation: subjectively intact to light touch;
PSYCHIATRIC: mental status: alert and oriented x 3; appropriate affect and demeanor;
Lab/Test Results:
LABORATORY RESULTS:
Urinalysis: (-) glucose, (-) bilirubin, (-) ketones, S.G. 1.020, trace blood, pH 6.5, (-) protein, normal (0.2-1 EU) urobilinogen, (-) nitrite, (-) leukocyte esterase; Hemocult: negative;
Procedures:
Annual exam
VISUAL ACUITY:
OS: 20/25 (uncorrected);
OD: 20/50 (uncorrected);
Cerumen impaction
Procedure: Cerumen impaction is noted in the right ear. The degree of wax accumulation is moderate in the right ear. With minimal difficulty, using a syringe irrigation, the wax is removed. Removed from ear was hard balls of wax. The patient tolerated the procedure well.
There were no complications.
ASSESSMENT:
V70.0 Annual exam
521.07 Dental caries of smooth surface
366.9 Cataract
380.4 Cerumen impaction
PLAN:
Annual exam
LABORATORY: Labs ordered to be performed today include, CBC, lipid panel, comprehensive metabolic panel, PSA, TSH, and urinalysis.
REFERRALS: Outside referral to a gastroenterologist ( to perform screening colonoscopy ).
Orders:
Collection of venous blood by venipuncture
Complete (CBC), automated (Hgb, Hct, RBC, WBC, and platelet count) and automated differential WBC co
Lipid panel (total cholesterol, HDL, triglycerides)
Comprehensive metabolic panel (Albumin, Bilirubin, Ca, CO2, Cl, Creatinine, Glu, alkaline phosphatas
PSA
Thyroid stimulating hormone (TSH)
Urinalysis, automated, without microscopy
Referral
Screening visual acuity, quantitative, bilateral
Dental caries of smooth surface
Prescriptions:
Penicillin VK 500mg Tablet Take 1 tablet(s) by mouth bid for 10 days #20 (Twenty) tablet(s) Refills: 0
Orders: Patient advised to schedule dental appointment ASAP, and agrees to comply.
Cataract
Orders: Patient advised to schedule optical evaluation, agrees to comply.
Cerumen impaction
Orders:
Removal impacted cerumen, one or both ears
Other Orders:
Blood occult, perioxidase activity, qualitative; feces for colorectal neoplasm screening
CHARGE CAPTURE:
Primary Diagnosis:
V70.0 Annual exam
Orders:
99387 Preventive medicine, new patient, age 65+ years
36415 Collection of venous blood by venipuncture
81003 Urinalysis, automated, without microscopy
REF Referral
99173 Screening visual acuity, quantitative, bilateral
521.07 Dental caries of smooth surface
Orders:
99202-25 Office/outpatient visit; new patient, level 2
366.9 Cataract
380.4 Cerumen impaction
Orders:
69210 Removal impacted cerumen, one or both ears
Other Orders:
82270 Blood occult, perioxidase activity, qualitative; feces for colorectal neoplasm screening
Thanks
Kristie Stokes, CPC-A
CC:
Mr. XX is a 69-year-old male. He is here for an annual exam.
HPI:
Patient complains of annual exam. His last physical exam was 4 years ago. He underwent colonoscopy 1979 years ago with normal results. He's had vision screening done 10 years ago and this was normal.
Smoking Status: Nonsmoker
ROS:
CONSTITUTIONAL: Negative for chills, fatigue, fever, and weight change.
EYES: Negative for blurred vision, eye pain, and photophobia.
E/N/T: Negative for hearing problems, E/N/T pain, congestion, rhinorrhea, epistaxis, hoarseness, and dental problems.
CARDIOVASCULAR: Negative for chest pain, palpitations, tachycardia, orthopnea, and edema.
RESPIRATORY: Negative for cough, dyspnea, and hemoptysis.
GASTROINTESTINAL: Negative for abdominal pain, heartburn, constipation, diarrhea, and stool changes.
MUSCULOSKELETAL: Negative for arthralgias, back pain, and myalgias.
NEUROLOGICAL: Negative for dizziness, headaches, paresthesias, and weakness.
HEMATOLOGIC/LYMPHATIC: Negative for easy bruising, bleeding, and lymphadenopathy.
ENDOCRINE: Negative for hair loss, heat/cold intolerance, polydipsia, and polyphagia.
PSYCHIATRIC: Negative for anxiety, depression, and sleep disturbances.
Immunizations:
None
Allergies:
No Known Drug Allergies.
Current Medications:
Valtrex 500mg Tablet take one tablet qd
OBJECTIVE:
Vitals:
Current: 2/26/2008 8:56:21 AM
Ht: 67 inches; Wt: 195 lbs; BMI: 30.54
T: 98 F (oral); BP: 138/77 mm Hg (left arm, sitting); P: 92 bpm (left arm (BP Cuff), sitting); R: 16 bpm
VA: 20/50 OD, 20/25 OS (without correction)
Exams:
GENERAL: well developed, well nourished, in no apparent distress
EYES: lids and conjunctiva are normal; PERRLA; EOMI; fundoscopic exam reveals bilateral loss of red reflex, left > right;
E/N/T: normal external ears and nose;; Ears: left TM is normal; left EAC is normal; right EAC is occluded by cerumen; Hearing Screen: Able to hear fingers rubbed together with both ears; Nose: normal nasal mucosa, septum, turbinates, and sinuses; Lips/Teeth/Gums: gingival edema; white ulcer right lower outer gum with dental caries right posterior molar into gum line Oropharynx: normal mucosa, palate, and posterior pharynx;
NECK: Neck is supple with full range of motion; thyroid is normal to palpation;
RESPIRATORY: normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs;
CARDIOVASCULAR: normal rate; regular rhythm; no murmurs carotids: 2+ amplitude, no bruits; 2+ pedal pulses; no edema;
GASTROINTESTINAL: normal bowel sounds; no masses or tenderness; no organomegaly rectal exam: normal tone; nontender, guaiac negative stool; guaiac negative stool;
GENITOURINARY: prostate: no nodules, tenderness, or enlargement;
LYMPHATIC: no enlargement of cervical nodes; right submandibular node;
MUSCULOSKELETAL: digits/nails: no clubbing, cyanosis, or evidence of ischemia or infection; normal gait; grossly normal tone and muscle strength; full, painless range of motion of all major muscle groups and joints no masses, effusions, misalignment, crepitus, or tenderness in major joints;
NEUROLOGIC: cranial nerves: 2-12 grossly intact; normal DTR's elicited in biceps, triceps, supinator, knee, and ankle jerk; sensation: subjectively intact to light touch;
PSYCHIATRIC: mental status: alert and oriented x 3; appropriate affect and demeanor;
Lab/Test Results:
LABORATORY RESULTS:
Urinalysis: (-) glucose, (-) bilirubin, (-) ketones, S.G. 1.020, trace blood, pH 6.5, (-) protein, normal (0.2-1 EU) urobilinogen, (-) nitrite, (-) leukocyte esterase; Hemocult: negative;
Procedures:
Annual exam
VISUAL ACUITY:
OS: 20/25 (uncorrected);
OD: 20/50 (uncorrected);
Cerumen impaction
Procedure: Cerumen impaction is noted in the right ear. The degree of wax accumulation is moderate in the right ear. With minimal difficulty, using a syringe irrigation, the wax is removed. Removed from ear was hard balls of wax. The patient tolerated the procedure well.
There were no complications.
ASSESSMENT:
V70.0 Annual exam
521.07 Dental caries of smooth surface
366.9 Cataract
380.4 Cerumen impaction
PLAN:
Annual exam
LABORATORY: Labs ordered to be performed today include, CBC, lipid panel, comprehensive metabolic panel, PSA, TSH, and urinalysis.
REFERRALS: Outside referral to a gastroenterologist ( to perform screening colonoscopy ).
Orders:
Collection of venous blood by venipuncture
Complete (CBC), automated (Hgb, Hct, RBC, WBC, and platelet count) and automated differential WBC co
Lipid panel (total cholesterol, HDL, triglycerides)
Comprehensive metabolic panel (Albumin, Bilirubin, Ca, CO2, Cl, Creatinine, Glu, alkaline phosphatas
PSA
Thyroid stimulating hormone (TSH)
Urinalysis, automated, without microscopy
Referral
Screening visual acuity, quantitative, bilateral
Dental caries of smooth surface
Prescriptions:
Penicillin VK 500mg Tablet Take 1 tablet(s) by mouth bid for 10 days #20 (Twenty) tablet(s) Refills: 0
Orders: Patient advised to schedule dental appointment ASAP, and agrees to comply.
Cataract
Orders: Patient advised to schedule optical evaluation, agrees to comply.
Cerumen impaction
Orders:
Removal impacted cerumen, one or both ears
Other Orders:
Blood occult, perioxidase activity, qualitative; feces for colorectal neoplasm screening
CHARGE CAPTURE:
Primary Diagnosis:
V70.0 Annual exam
Orders:
99387 Preventive medicine, new patient, age 65+ years
36415 Collection of venous blood by venipuncture
81003 Urinalysis, automated, without microscopy
REF Referral
99173 Screening visual acuity, quantitative, bilateral
521.07 Dental caries of smooth surface
Orders:
99202-25 Office/outpatient visit; new patient, level 2
366.9 Cataract
380.4 Cerumen impaction
Orders:
69210 Removal impacted cerumen, one or both ears
Other Orders:
82270 Blood occult, perioxidase activity, qualitative; feces for colorectal neoplasm screening
Thanks
Kristie Stokes, CPC-A