need E/M help

perkins05

Expert
Messages
296
Location
New Orleans
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Is this a PE or problem visit?

ALLERGIES:
Onset Description Reaction
05/10/2000 No Known Allergies

PROBLEM:
CHIEF COMPLAINT:
wellness exam

SUBJECTIVE:
Patient presents with wellness exam.
Comments: Eats a lot of fast food. Records show weight gain of > 40 lb since 2005. Brings bp diary; see scanned diary. Mult readings borderline or high.


Chronic Conditions:

none

REVIEW OF SYSTEMS:

Health Maintenance:
Last tetanus on 10/31/2005.
Last Eye Exam done on 04/24/2008.
Last Pap Smear done on 06/15/2010.
Health Maintenance Comments: had abnormal pap, had repeat at oschner, need update.

has reviewed and updated the past medical, social and family history.

OBJECTIVE:
Vital Signs:
Temperature: 98.20 by: oral Weight: 173.80 lbs Height: 63.00 in Head Circumference:
Pulse: 89/min
Respiration: 18/min
Blood Pressure: Position Location Cuff
120/ 90 sitting left arm regular Pain Rating Scale:
Pain rated as 0 by : patient
Patients BMI is 30.86 .

Physical Exam:
General:
The patient is in no apparent distress.
The patient is moderately obese.

HEENT:
Head:
Neck:
The neck is supple without thyromegaly, JVD, lymphadenopathy or carotid bruits.
Ears:
The ear canals are clear. The tympanic membranes are intact bilaterally.
Mouth & Throat:
The oropharynx is benign.

Lungs:
The chest is clear to auscultation and percussion. The breath sounds are equal bilaterally.

Heart:
The heart reveals a regular rate and rhythm with a normal S1 and S2. There are no murmurs or gallops appreciated.

ASSESSMENT:
Code Diagnosis
796.2 ELEV BL PRES W/O HYPERTN
V70.0 ROUTINE MEDICAL EXAM
783.1 ABNORMAL WEIGHT GAIN



PLAN:
MEDICATION:
Brand Generic Name Dose Sig Desc
Z-pack Azithromycin Take as directed
Sprintec Norgestimate-ethinyl Estradiol 0.25-0.035
The medications have been reviewed by:.

The following panel (s) were ordered:
Panels
General Health Panel
Lipid Total [Care Panel #2]
Lab Tech Comments: q/db
Urinalysis
Urine Auto w/o Microscope




Plan notes: Wellness exam. Given and discussed info on htn, aerobic exercise and DASH diet. Begin exercise at least 1/2 hr per day. Discussed gardasil vaccine; requested copy of shot records. She will discuss gardasil with her gynecologist. Bring bp diary on f/u.
Follow up: 3month(s)
Follow up: PRN


Patient Education:
General Education Discussed:
Diet specifics discussed with patient/responsible party. Exercise program discussed with patient/ responsible party. Monitoring outpatient BPs discussed with patient/responsible party.
Patient urged to lose weight/continue efforts.
 

mitchellde

True Blue
Messages
13,430
Location
Columbia, MO
Best answers
1
This is definitely a PE the V70.0 must be first listed you can include the other 2 dx codes but it will not change the CPT assignment of preventive level.
 
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