buttafly
Contributor
CIGNA DENIED BILLING 99204-25 WITH 62328.
Should we bill an office visit with the information below?
History of Present Illness
• Allergy list reviewed • Problem list reviewed • Medication list reviewed
XX year old with recent onset of dementia symptoms. Pt sent for CSF collection for diagnostic analysis
Current Medication
• Aricept 10 MG Oral Tablet 1 by mouth at bedtime, 90 days, 3 refills
• CVS Vitamin B12 1000 MCG Oral Tablet 1 by mouth once a day 0 days, 0 refills
• Vitamin D3 50 MCG (2000 UT) Oral Capsule 1 by mouth once a day 0 days, 0 refills
• Tylenol 500 OTC
• predniSONE 20 MG Oral Tablet 2 po daily for 2 weeks, then 1.5 tab po daily for 2 weeks, then 1 po daily for 2 weeks, then 1/2 po daily and stay on this dose. TAke in AM., 90 days, 0 refills
Medication list reviewed and reconciled by comparing our medical record to an external list of medications obtained from patient, hospital, or other provider including all available resources at the time of this visit, and including prescriptions, over-the-counter, herbals, and supplements.
• • Medication information obtained 3/10/2024: E-FORCSE Accessed
Allergies/Adverse Reactions
• NSAID
Past Medical/Surgical History
Diagnoses:
Anxiety disorder
Surgical:
• ankle sugery
• Dental implants
Review Of Systems
Physician's Services:• Patient screened for future fall risk:
1.Have you fallen in the last year?
2.If so how many times?
3.Did you sustain any injuries from falling? If so what?
4.Have you cut back on your activities because you are unsteady?• Patient screened for future fall risk: documentation of no falls in past year
Physical Findings
• Vitals taken 03/10/2024 08.10 am
BP-Sitting R180/77 mmHg
BP Cuff Size: Regular
Pulse Rate-Sitting 81 bpm
Height 64 in
Weight157 lbs
Pain Level0
Injection site skin without abnormality, no evidence of infection/rash
Social History
Tobacco use: No tobacco used. Smoking status: Never smoker.
Alcohol: Alcohol use: doesn’t drink.
Drug Use: Never used drugs.
Education: Some College.
Work: Retired from work.
• Use of tobacco assessment performed
Family History
Maternal:
Anxiety disorder
Sororal:
dementia
Active Problems & Conditions
• Adjustment Disorder with Anxiety
• Dementia of Unknown (Axis III) Etiology Without Behavioral Disturbance
• Memory Lapses Or Loss
Assessment
• Body mass index
Discussed Diagnostic CSF needed
Risks (including spinal headache), benefits and alternatives of the procedure discussed and all questions answered.
Plan
• CSF
Procedure
Diagnostic Interlaminar intrathecal collection of CSF using fluor
The patient was informed of choices, risks, benefits, possible complications and informed written consent was obtained.
The patient denied allergies to the medications used. The patient was escorted to the fluoroscopy suite and positioned in a decubitus position. Pillows were placed for support and comfort. After a time out confirming correct patient and procedure the patients lumbar back was prepped with chlorhexidine and draped in a sterile fashion. Using fluoroscopic guidance over the L5S1 interspace, the skin and subcutaneous tissues were anesthetized with 5cc of PF 1% lidocaine using a 1.5 inch needle. Next, a 22 gauge spinal needle with a quinc needle was placed and advanced The fluoroscopy view was changed to lateral and intrathecal space was entered without paresthesia. An opening pressure was obtained via manometry recorded and then spinal fluid was collected and recorded. The spinal needle was then removed. The patient tolerated the procedure well and there were no complications. A dressing was placed and the patient was transported to the recovery area. After a period of observation while lying supine, the patient was discharged home with instructions
Should we bill an office visit with the information below?
History of Present Illness
• Allergy list reviewed • Problem list reviewed • Medication list reviewed
XX year old with recent onset of dementia symptoms. Pt sent for CSF collection for diagnostic analysis
Current Medication
• Aricept 10 MG Oral Tablet 1 by mouth at bedtime, 90 days, 3 refills
• CVS Vitamin B12 1000 MCG Oral Tablet 1 by mouth once a day 0 days, 0 refills
• Vitamin D3 50 MCG (2000 UT) Oral Capsule 1 by mouth once a day 0 days, 0 refills
• Tylenol 500 OTC
• predniSONE 20 MG Oral Tablet 2 po daily for 2 weeks, then 1.5 tab po daily for 2 weeks, then 1 po daily for 2 weeks, then 1/2 po daily and stay on this dose. TAke in AM., 90 days, 0 refills
Medication list reviewed and reconciled by comparing our medical record to an external list of medications obtained from patient, hospital, or other provider including all available resources at the time of this visit, and including prescriptions, over-the-counter, herbals, and supplements.
• • Medication information obtained 3/10/2024: E-FORCSE Accessed
Allergies/Adverse Reactions
• NSAID
Past Medical/Surgical History
Diagnoses:
Anxiety disorder
Surgical:
• ankle sugery
• Dental implants
Review Of Systems
Physician's Services:• Patient screened for future fall risk:
1.Have you fallen in the last year?
2.If so how many times?
3.Did you sustain any injuries from falling? If so what?
4.Have you cut back on your activities because you are unsteady?• Patient screened for future fall risk: documentation of no falls in past year
Physical Findings
• Vitals taken 03/10/2024 08.10 am
BP-Sitting R180/77 mmHg
BP Cuff Size: Regular
Pulse Rate-Sitting 81 bpm
Height 64 in
Weight157 lbs
Pain Level0
Injection site skin without abnormality, no evidence of infection/rash
Social History
Tobacco use: No tobacco used. Smoking status: Never smoker.
Alcohol: Alcohol use: doesn’t drink.
Drug Use: Never used drugs.
Education: Some College.
Work: Retired from work.
• Use of tobacco assessment performed
Family History
Maternal:
Anxiety disorder
Sororal:
dementia
Active Problems & Conditions
• Adjustment Disorder with Anxiety
• Dementia of Unknown (Axis III) Etiology Without Behavioral Disturbance
• Memory Lapses Or Loss
Assessment
• Body mass index
Discussed Diagnostic CSF needed
Risks (including spinal headache), benefits and alternatives of the procedure discussed and all questions answered.
Plan
• CSF
Procedure
Diagnostic Interlaminar intrathecal collection of CSF using fluor
The patient was informed of choices, risks, benefits, possible complications and informed written consent was obtained.
The patient denied allergies to the medications used. The patient was escorted to the fluoroscopy suite and positioned in a decubitus position. Pillows were placed for support and comfort. After a time out confirming correct patient and procedure the patients lumbar back was prepped with chlorhexidine and draped in a sterile fashion. Using fluoroscopic guidance over the L5S1 interspace, the skin and subcutaneous tissues were anesthetized with 5cc of PF 1% lidocaine using a 1.5 inch needle. Next, a 22 gauge spinal needle with a quinc needle was placed and advanced The fluoroscopy view was changed to lateral and intrathecal space was entered without paresthesia. An opening pressure was obtained via manometry recorded and then spinal fluid was collected and recorded. The spinal needle was then removed. The patient tolerated the procedure well and there were no complications. A dressing was placed and the patient was transported to the recovery area. After a period of observation while lying supine, the patient was discharged home with instructions