jeaner54175@yahoo.com
Networker
Can someone review this dictation and let me know if they would use a medicare wellness exam code along with an evaluation and management code with modifier 25. The patient has medicare and came in for a physical. The provider used a preventive medicine services code (which isn't covered by medicare) and an office visit code with modifier 25. I feel some of the guidelines were met for the wellness exam but would like another opinion.
Subjective: 44-year-old male with multiple problems presents for physical exam and fasting lab work.
HPI
has a past medical history of hypertension, hyperlipidemia, and type 2 diabetes. Since he lost weight, which in the last 8-9 months he has lost over 60 pounds, he has not had to take metformin and his blood sugars are normal. He does not know why he lost the weight. He has not changed his eating habits. He has no nausea, vomiting or diarrhea, although he does state that on occasion his bowel pattern can be abnormal with some constipation and some diarrhea at times. He did have a colonoscopy several.
His blood pressure is elevated, although he has not been on any medications. He also has other multiple issues today and chronically. He states his vision has been bothering him with his left eye having black spots in it that's been going on for about a month or so. His right shoulder has been progressively worse since then bothering him for over a year. He has no specific injury but it's been getting progressively worse, especially over the last 3 months. He has decreased range of motion with his right shoulder and soreness in the subscapular area. We have not gotten an x-ray and we have not seen him for this problem. He states his trapezius muscle tightens up and then he has headaches and neck pain also.
He has a history of asthma. He has not been using any inhalers. He has shortness of breath and wheezing that is audible without a stethoscope. We will get him started on his medication for asthma which is Qvar and albuterol. He is continuing to smoke but is smoking a half a pack a day compared to one pack. He is interested in quitting and would like to try Chantix which we will start. He states the cough has been going on for quite a while and he coughed up at least 12 ounces of milky white phlegm every morning. He has no fever or chills.
He has urinary pressure and dysuria with hesitancy and urgency and what sounds like potential benign prostatic hypertrophy. We will be getting a urine sample today along with a PSA.
Complains of fluid in his ear that never seems to leave. He tried Flonase nasal spray and Sudafed without relief. I did remind him that tobacco use will cause fluid buildup in the ears. He also complains of TMJ symptoms and pain in the left upper jaw because of a dental infection. He does have a dental appointment coming up. He does complain of some sinus symptoms.
Complains about getting sleepy or fatigued even though he has plenty of sleep. He apparently is on disability and just moved back to the area. He lives with his sister, but there is some social concerns. He stated that she will take half of his income.
Review of Systems
Constitutional: Positive for weight loss. Negative for fever, chills, malaise/fatigue and diaphoresis.
HENT: Positive for neck pain. Negative for hearing loss, ear pain, congestion and sore throat.
Eyes: Positive for blurred vision.
Left eye describes as seeing black spots and also described as a black shadow. This is been present, I believe he said for the last month.
Respiratory: Positive for cough, sputum production, shortness of breath and wheezing.
See HPI
Cardiovascular: Negative for chest pain, palpitations, orthopnea, claudication and leg swelling.
Gastrointestinal: Positive for diarrhea and constipation. Negative for heartburn, nausea, vomiting, abdominal pain, blood in stool and melena.
Genitourinary: Positive for dysuria and urgency.
Hesitancy and sometimes a weak stream.
Musculoskeletal: Positive for myalgias and joint pain.
Right shoulder pain and neck pain in the trapezius area. Also complains of right knee pain, we did not address that today
Skin: Positive for itching and rash.
Perianal area has a rash with itching. No hemorrhoids
Neurological: Positive for headaches. Negative for dizziness, tingling, tremors, sensory change, speech change, focal weakness, seizures, loss of consciousness and weakness.
Endo/Heme/Allergies:
Complains that he bruises easily and on the inner aspect of his right knee he had a grapefruit-sized bruise the other day. It is not present today.
Psychiatric/Behavioral: Positive for depression and substance abuse. Negative for suicidal ideas and hallucinations.
He has a history of depression and he was seen today by our health counselor who will be in touch with him regarding counseling.
Smoking cessation issues, reviewed the use of Chantix and prescription provided.
Objective:
Filed Vitals:
BP:
158/90
Pulse:
100
Temp:
98.2 ?F (36.8 ?C)
Resp:
22
Height:
6' (1.829 m)
Weight:
203 lb (92.08 kg)
Estimated body mass index is 27.53 kg/(m^2) as calculated from the following:
Height as of this encounter: 6' (1.829 m).
Weight as of this encounter: 203 lb (92.08 kg).
Normalized BMI data available only for age 2 to 20 years.
Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. No distress.
HENT:
Head: Normocephalic and atraumatic.
Fluid and dullness in bilateral TMs.
Jaw clicking noted. Dental caries noted on exam in the left upper jawline. Pain to palpation in the left maxillary sinus, not sure this is dental related, or sinusitis.
Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus.
Neck: Neck supple. No JVD present. No tracheal deviation present. Thyromegaly present.
The thyroid was palpable but not excessive in size and was symmetrical. A TSH level is pending
Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop and no friction rub.
No murmur heard.
Pulmonary/Chest: Breath sounds normal. He is in respiratory distress. He has no wheezes. He has no rales. He exhibits no tenderness.
Abdominal: Soft. Bowel sounds are normal. He exhibits no distension and no mass. There is tenderness. There is no rebound and no guarding.
Tenderness of the right upper quadrant and palpation of the edge of the liver caused discomfort and suggested some enlargement.
Genitourinary: Rectum normal.
Prostate did seem enlarged with a very shallow sulcus, no nodules and it was firm and seemed symmetrical. PSA level pending, and probable urology referral.
Musculoskeletal: He exhibits tenderness. He exhibits no edema.
Right shoulder exam and tenderness to palpation at the a.c. Joint, none at the coracoid process, no pain at the deltoid insertion, pain to palpation at the subscapular area.
Range of motion mildly impaired in abduction, forward flexion and internal rotation. Referral for physical therapy.
Lymphadenopathy:
He has no cervical adenopathy.
Neurological: He is alert and oriented to person, place, and time. He displays normal reflexes. No cranial nerve deficit. He exhibits normal muscle tone. Coordination normal.
Skin: Skin is warm and dry.
Psychiatric: He has a normal mood and affect. His behavior is normal.
Assessment and Plan:
V70.9 Physical exam (primary encounter diagnosis)
Plan : COMPREHENSIVE METABOLIC PANEL
CBC W/AUTO DIFF (IN-HOUSE/POCT) 85025
THYROID STIMULATING HORMONE (TSH)
HGB A1C FINGERSTICK (83036)
LIPID PANEL (POCT) 80061
URINALYSIS (DIP ONLY), IN HOUSE (81002)
URINE CULTURE W ID & SENS
PROSTATE SPECIFIC ANTIGEN W/RFLX PSA FREE
PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL
783.21 Weight loss, unintentional
Plan : COMPREHENSIVE METABOLIC PANEL
CBC W/AUTO DIFF (IN-HOUSE/POCT) 85025
THYROID STIMULATING HORMONE (TSH)
HGB A1C FINGERSTICK (83036)
LIPID PANEL (POCT) 80061
SKIN TEST; TUBERCULOSIS, INTRADERMAL
REFERRAL TO IMAGING
719.41 Chronic right shoulder pain
Plan : TIZANIDINE 4 MG TABLET - Take 1 Tab by mouth
every 6 (six) hours as needed for muscle
spasms. Do not exceed 24 mg in 24 hours.
REFERRAL TO PHYSICAL THERAPY
REFERRAL TO IMAGING
491.1 Chronic bronchitis with productive mucopurulent cough
Plan : COMPREHENSIVE METABOLIC PANEL
CBC W/AUTO DIFF (IN-HOUSE/POCT) 85025
SKIN TEST; TUBERCULOSIS, INTRADERMAL
REFERRAL TO IMAGING
401.9 Hypertension
Plan : COMPREHENSIVE METABOLIC PANEL
CBC W/AUTO DIFF (IN-HOUSE/POCT) 85025
THYROID STIMULATING HORMONE (TSH)
LIPID PANEL (POCT) 80061
REFERRAL TO IMAGING
272.4 Hyperlipidemia
Plan : COMPREHENSIVE METABOLIC PANEL
CBC W/AUTO DIFF (IN-HOUSE/POCT) 85025
THYROID STIMULATING HORMONE (TSH)
HGB A1C FINGERSTICK (83036)
LIPID PANEL (POCT) 80061
788.63 Urinary urgency
Plan : URINALYSIS (DIP ONLY), IN HOUSE (81002)
URINE CULTURE W ID & SENS
PROSTATE SPECIFIC ANTIGEN W/RFLX PSA FREE
PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL
401.9 High blood pressure
Plan : LISINOPRIL 20 MG TABLET - Take 1 Tab by mouth
once daily.
305.1 Tobacco abuse
Plan : VARENICLINE 0.5 MG (11)-1 MG (42) TABLETS IN A
DOSE PACK - Take one 0.5mg tab once daily for
first 3 days, then 0.5mg tab twice daily for 4
days, then 1mg tab twice daily.
REFERRAL TO IMAGING
522.4 Dental infection
Plan : AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG
TABLET - Take 1 Tab by mouth 2 (two) times
daily.
473.9 Chronic recurrent sinusitis
Plan : AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG
TABLET - Take 1 Tab by mouth 2 (two) times
daily.
V03.7 Need for tetanus booster
Plan : TDAP (7 + YEARS)
493.90 Asthma in adult
Plan : ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL
INHALER - Inhale 2 Puffs into the lungs every 4
(four) hours as needed for shortness of breath
or wheezing.
BECLOMETHASONE DIPROPIONATE 80 MCG/ACTUATION
AEROSOL INHALER - Inhale 2 Puffs into the lungs
2 (two) times daily.
491.1 Chronic bronchitis, mucopurulent
Plan : ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL
INHALER - Inhale 2 Puffs into the lungs every 4
(four) hours as needed for shortness of breath
or wheezing.
BECLOMETHASONE DIPROPIONATE 80 MCG/ACTUATION
AEROSOL INHALER - Inhale 2 Puffs into the lungs
2 (two) times daily.
794.13 Visually evoked potential abnormality
Plan : REFERRAL TO OPHTHALMOLOGY
112.2 Candidiasis of perineum
Plan : CLOTRIMAZOLE 1 % TOPICAL CREAM - Apply
topically 2 (two) times daily. to the perineal rectal area
Subjective: 44-year-old male with multiple problems presents for physical exam and fasting lab work.
HPI
has a past medical history of hypertension, hyperlipidemia, and type 2 diabetes. Since he lost weight, which in the last 8-9 months he has lost over 60 pounds, he has not had to take metformin and his blood sugars are normal. He does not know why he lost the weight. He has not changed his eating habits. He has no nausea, vomiting or diarrhea, although he does state that on occasion his bowel pattern can be abnormal with some constipation and some diarrhea at times. He did have a colonoscopy several.
His blood pressure is elevated, although he has not been on any medications. He also has other multiple issues today and chronically. He states his vision has been bothering him with his left eye having black spots in it that's been going on for about a month or so. His right shoulder has been progressively worse since then bothering him for over a year. He has no specific injury but it's been getting progressively worse, especially over the last 3 months. He has decreased range of motion with his right shoulder and soreness in the subscapular area. We have not gotten an x-ray and we have not seen him for this problem. He states his trapezius muscle tightens up and then he has headaches and neck pain also.
He has a history of asthma. He has not been using any inhalers. He has shortness of breath and wheezing that is audible without a stethoscope. We will get him started on his medication for asthma which is Qvar and albuterol. He is continuing to smoke but is smoking a half a pack a day compared to one pack. He is interested in quitting and would like to try Chantix which we will start. He states the cough has been going on for quite a while and he coughed up at least 12 ounces of milky white phlegm every morning. He has no fever or chills.
He has urinary pressure and dysuria with hesitancy and urgency and what sounds like potential benign prostatic hypertrophy. We will be getting a urine sample today along with a PSA.
Complains of fluid in his ear that never seems to leave. He tried Flonase nasal spray and Sudafed without relief. I did remind him that tobacco use will cause fluid buildup in the ears. He also complains of TMJ symptoms and pain in the left upper jaw because of a dental infection. He does have a dental appointment coming up. He does complain of some sinus symptoms.
Complains about getting sleepy or fatigued even though he has plenty of sleep. He apparently is on disability and just moved back to the area. He lives with his sister, but there is some social concerns. He stated that she will take half of his income.
Review of Systems
Constitutional: Positive for weight loss. Negative for fever, chills, malaise/fatigue and diaphoresis.
HENT: Positive for neck pain. Negative for hearing loss, ear pain, congestion and sore throat.
Eyes: Positive for blurred vision.
Left eye describes as seeing black spots and also described as a black shadow. This is been present, I believe he said for the last month.
Respiratory: Positive for cough, sputum production, shortness of breath and wheezing.
See HPI
Cardiovascular: Negative for chest pain, palpitations, orthopnea, claudication and leg swelling.
Gastrointestinal: Positive for diarrhea and constipation. Negative for heartburn, nausea, vomiting, abdominal pain, blood in stool and melena.
Genitourinary: Positive for dysuria and urgency.
Hesitancy and sometimes a weak stream.
Musculoskeletal: Positive for myalgias and joint pain.
Right shoulder pain and neck pain in the trapezius area. Also complains of right knee pain, we did not address that today
Skin: Positive for itching and rash.
Perianal area has a rash with itching. No hemorrhoids
Neurological: Positive for headaches. Negative for dizziness, tingling, tremors, sensory change, speech change, focal weakness, seizures, loss of consciousness and weakness.
Endo/Heme/Allergies:
Complains that he bruises easily and on the inner aspect of his right knee he had a grapefruit-sized bruise the other day. It is not present today.
Psychiatric/Behavioral: Positive for depression and substance abuse. Negative for suicidal ideas and hallucinations.
He has a history of depression and he was seen today by our health counselor who will be in touch with him regarding counseling.
Smoking cessation issues, reviewed the use of Chantix and prescription provided.
Objective:
Filed Vitals:
BP:
158/90
Pulse:
100
Temp:
98.2 ?F (36.8 ?C)
Resp:
22
Height:
6' (1.829 m)
Weight:
203 lb (92.08 kg)
Estimated body mass index is 27.53 kg/(m^2) as calculated from the following:
Height as of this encounter: 6' (1.829 m).
Weight as of this encounter: 203 lb (92.08 kg).
Normalized BMI data available only for age 2 to 20 years.
Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. No distress.
HENT:
Head: Normocephalic and atraumatic.
Fluid and dullness in bilateral TMs.
Jaw clicking noted. Dental caries noted on exam in the left upper jawline. Pain to palpation in the left maxillary sinus, not sure this is dental related, or sinusitis.
Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus.
Neck: Neck supple. No JVD present. No tracheal deviation present. Thyromegaly present.
The thyroid was palpable but not excessive in size and was symmetrical. A TSH level is pending
Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop and no friction rub.
No murmur heard.
Pulmonary/Chest: Breath sounds normal. He is in respiratory distress. He has no wheezes. He has no rales. He exhibits no tenderness.
Abdominal: Soft. Bowel sounds are normal. He exhibits no distension and no mass. There is tenderness. There is no rebound and no guarding.
Tenderness of the right upper quadrant and palpation of the edge of the liver caused discomfort and suggested some enlargement.
Genitourinary: Rectum normal.
Prostate did seem enlarged with a very shallow sulcus, no nodules and it was firm and seemed symmetrical. PSA level pending, and probable urology referral.
Musculoskeletal: He exhibits tenderness. He exhibits no edema.
Right shoulder exam and tenderness to palpation at the a.c. Joint, none at the coracoid process, no pain at the deltoid insertion, pain to palpation at the subscapular area.
Range of motion mildly impaired in abduction, forward flexion and internal rotation. Referral for physical therapy.
Lymphadenopathy:
He has no cervical adenopathy.
Neurological: He is alert and oriented to person, place, and time. He displays normal reflexes. No cranial nerve deficit. He exhibits normal muscle tone. Coordination normal.
Skin: Skin is warm and dry.
Psychiatric: He has a normal mood and affect. His behavior is normal.
Assessment and Plan:
V70.9 Physical exam (primary encounter diagnosis)
Plan : COMPREHENSIVE METABOLIC PANEL
CBC W/AUTO DIFF (IN-HOUSE/POCT) 85025
THYROID STIMULATING HORMONE (TSH)
HGB A1C FINGERSTICK (83036)
LIPID PANEL (POCT) 80061
URINALYSIS (DIP ONLY), IN HOUSE (81002)
URINE CULTURE W ID & SENS
PROSTATE SPECIFIC ANTIGEN W/RFLX PSA FREE
PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL
783.21 Weight loss, unintentional
Plan : COMPREHENSIVE METABOLIC PANEL
CBC W/AUTO DIFF (IN-HOUSE/POCT) 85025
THYROID STIMULATING HORMONE (TSH)
HGB A1C FINGERSTICK (83036)
LIPID PANEL (POCT) 80061
SKIN TEST; TUBERCULOSIS, INTRADERMAL
REFERRAL TO IMAGING
719.41 Chronic right shoulder pain
Plan : TIZANIDINE 4 MG TABLET - Take 1 Tab by mouth
every 6 (six) hours as needed for muscle
spasms. Do not exceed 24 mg in 24 hours.
REFERRAL TO PHYSICAL THERAPY
REFERRAL TO IMAGING
491.1 Chronic bronchitis with productive mucopurulent cough
Plan : COMPREHENSIVE METABOLIC PANEL
CBC W/AUTO DIFF (IN-HOUSE/POCT) 85025
SKIN TEST; TUBERCULOSIS, INTRADERMAL
REFERRAL TO IMAGING
401.9 Hypertension
Plan : COMPREHENSIVE METABOLIC PANEL
CBC W/AUTO DIFF (IN-HOUSE/POCT) 85025
THYROID STIMULATING HORMONE (TSH)
LIPID PANEL (POCT) 80061
REFERRAL TO IMAGING
272.4 Hyperlipidemia
Plan : COMPREHENSIVE METABOLIC PANEL
CBC W/AUTO DIFF (IN-HOUSE/POCT) 85025
THYROID STIMULATING HORMONE (TSH)
HGB A1C FINGERSTICK (83036)
LIPID PANEL (POCT) 80061
788.63 Urinary urgency
Plan : URINALYSIS (DIP ONLY), IN HOUSE (81002)
URINE CULTURE W ID & SENS
PROSTATE SPECIFIC ANTIGEN W/RFLX PSA FREE
PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL
401.9 High blood pressure
Plan : LISINOPRIL 20 MG TABLET - Take 1 Tab by mouth
once daily.
305.1 Tobacco abuse
Plan : VARENICLINE 0.5 MG (11)-1 MG (42) TABLETS IN A
DOSE PACK - Take one 0.5mg tab once daily for
first 3 days, then 0.5mg tab twice daily for 4
days, then 1mg tab twice daily.
REFERRAL TO IMAGING
522.4 Dental infection
Plan : AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG
TABLET - Take 1 Tab by mouth 2 (two) times
daily.
473.9 Chronic recurrent sinusitis
Plan : AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG
TABLET - Take 1 Tab by mouth 2 (two) times
daily.
V03.7 Need for tetanus booster
Plan : TDAP (7 + YEARS)
493.90 Asthma in adult
Plan : ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL
INHALER - Inhale 2 Puffs into the lungs every 4
(four) hours as needed for shortness of breath
or wheezing.
BECLOMETHASONE DIPROPIONATE 80 MCG/ACTUATION
AEROSOL INHALER - Inhale 2 Puffs into the lungs
2 (two) times daily.
491.1 Chronic bronchitis, mucopurulent
Plan : ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL
INHALER - Inhale 2 Puffs into the lungs every 4
(four) hours as needed for shortness of breath
or wheezing.
BECLOMETHASONE DIPROPIONATE 80 MCG/ACTUATION
AEROSOL INHALER - Inhale 2 Puffs into the lungs
2 (two) times daily.
794.13 Visually evoked potential abnormality
Plan : REFERRAL TO OPHTHALMOLOGY
112.2 Candidiasis of perineum
Plan : CLOTRIMAZOLE 1 % TOPICAL CREAM - Apply
topically 2 (two) times daily. to the perineal rectal area