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NEED HELP!!! How do you code this E/M? Gardasil shot

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CHIEF COMPLAINT: 15 year old female established patient presents with lump on left breast. HISTORY OF PRESENT ILLNESS: Patient presents with a breast lump. Pt states she first noticed about 1 week ago. Not painful. Patient feeling well. No pain with the lump. Affects outer left quadrant of the left breast and affects the left breast at the 3 o'clock position. Rated as mild. Has shown no change since onset. Denies associated nipple discharge, rash, skin changes and skin irritation. REVIEW OF SYSTEMS: Const: Denies chills, fatigue, fever and weight change. General health stated as good. CV: Denies chest pain and palpitations. Resp: Denies cough, dyspnea and wheezing. GI: Denies constipation, diarrhea, dyspepsia, dysphagia, hematochezia, melena, nausea and vomiting. GU: Genital: denies dysmenorrheal, irregular menstrual periods and breast tenderness. Urinary: denies dysuria, frequency, hematuria, incontinence, nocturia and urgency. Musculo: Denies arthralgias and myalgia. Skin: Denies rashes. Neuro: Denies dizziness and lightheadedness. Current Meds: none Allergies: NKDAPAST MEDICAL HISTORY: Eye exam in 2006. No medical problems. Pt had eye surgery for lazy eye at 18 mos of age. FAMILY HISTORY: Diabetes Mellitus II, Hypertension, Breast Cancer, and Heart Disease. Mom had breast cancer in 2000 at age 44. She has not had an reoccurrence of breast cancer. MGM also has breast cancer.SOCIAL HISTORY: Former cigarette smoke – quit beginning 10-07. The child lives with the mother and two sisters. The home is smoke free.EXAM: BP: 118/80, Pulse: 72, Temp: 97.1, Resp: 16, Ht: 68”, Wt: 128 lbs, BMI: 19.5. Const: Appears well and comfortable. No signs of apparent distress present. Resp: Respiration rate is normal. No wheezing. Ausculate good airflow. Lungs are clear bilaterally. CV: Rate is regular. Rhythm is regular. No heart murmur appreciated. Extremities: No clubbing, cyanosis or edema. Breasts: Breast exam was performed while patient was in a supine position. Exam was done with a chaperone present, mother in room. Breasts normal on inspection. There are no skin changes. Left cyst, located at 2 o'clock position and left breast is nontender. Right breast is normal. Cyst round in the skin and not the breast tissue. Was able to pick it up and move it around. Pea size. Nipples: No discharge of the nipples bilaterally. Axillae: Axillae normal. Musculo: Walks with a normal gait. Skin: Skin in warm and dry.ASSESSMENT & PLAN: Left breast lump. I will get a ultrasound of the left breast. I instructed the patient to follow up after the test and also if the symptoms get worse or changes. I will give her Gardasil #2 shot today. HPI=Detailed, EXAM=Expanded Problem Focused, MDM=Moderate
 

jdibble

True Blue
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Daytona Beach, FL
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Based on the documentation, I think your Exam would be Detailed - Constitutional, Repiratory, Cardio, Muscular, and detailed skin) rather than Expanded. The HPI is Detailed (4+ HPI, 3 PFHS and 9 ROS) and the MDM is Moderate ( new problem = 3, undiagnosed new problem with uncertain prognosis = Moderate Risk, Data reviewed, 1 test ordered = 1). So for an established patient the level would be 99214. Even if the Exam was still Expanded, the other two areas would still fall under the 99214.

With the Gardisil shot you would bill this as 99214-25 with the dx for the breast lump, 90649 for the Gardisil vaccine, and 90471 for the Administration with diagnosis code V04.89 for the Gardisil and injection.

Hope this helps. :)

Thanks,
 
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