New Patient E&M - Clarification

LeaHarris

Networker
Messages
54
Best answers
0
In reviewing the following new patient office visits I "scored" the visits lower than my provider before I request the change, I want to make sure I am not missing anything?

First Patient: (provider bills 99204, I score 99203)

HPI - Patient is a 23 year old female is here for fainting.
Fainting
-was getting out of bed and took a couple steps and fainted
-she lost consouisness and fell on her left side
-thinks that she lost consouisness for about ten seconds
-has a slight headache right know
-a couple weeks ago she was getting out of bed and she kind of collapsed but she does not think she lost consouisness *
-has been getting dizzy-feeling like she will pass out- when she is running
-she feels like she is going to collapse
-she feels that if she does not turn her head and just look straight forward that it helps with the dizziness *
-she runs 3-4 times a week *
-goes through periods where she would have vertigo when she gets up from sitting or squatting

Review of Systems
Constitutional: Negative for fever, chills and malaise/fatigue.
Cardiovascular: Negative for chest pain.
Gastrointestinal: Negative for nausea, vomiting, diarrhea and constipation.
Genitourinary: Negative for dysuria, urgency and frequency.
Neurological: Negative for dizziness, weakness and headaches.
**

Current Outpatient Prescriptions*
Medication* Sig* Dispense* Refill*
•* FLUoxetine (PROZAC) 20 mg capsule* Take 20 mg by mouth once daily.* * *
**

No current facility-administered medications for this visit.*


Objective
**

Vitals

Filed Vitals:*
* 07/25/16 1311*
BP:* 101/60*
Pulse:* 60*
Temp:* 98 °F (36.7 °C)*
TempSrc:* Oral*
Resp:* 15*
Height:* 4' 11.25" (1.505 m)*
Weight:* 113 lb 6.4 oz (51.438 kg)*
SpO2:* 97%*


Estimated body mass index is 22.71 kg/(m^2) as calculated from the following:
* Height as of this encounter: 4' 11.25" (1.505 m).
* Weight as of this encounter: 113 lb 6.4 oz (51.438 kg).
Normalized BMI data available only for age 2 to 20 years.

BP Readings from Last 3 Encounters:*
07/25/16* 101/60*
11/20/13* 98/66*


Wt Readings from Last 3 Encounters:*
07/25/16* 113 lb 6.4 oz (51.438 kg)*
11/20/13* 104 lb (47.174 kg)*


Physical Exam
HENT: *
Head: Normocephalic and atraumatic.
Right Ear: Hearing, tympanic membrane, external ear and ear canal normal.
Left Ear: Hearing, tympanic membrane, external ear and ear canal normal. *
Nose: Nose normal. *
Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate.
Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge.
Neck: Normal range of motion. Neck supple. No thyromegaly present.
Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses.* Exam reveals no friction rub.* *
No murmur heard.
Pulmonary/Chest: Effort normal and breath sounds normal.
Abdominal: Soft. Bowel sounds are normal.
Musculoskeletal: Normal range of motion. She exhibits no edema.
Neurological: She is alert. She has normal strength. No cranial nerve deficit. She displays a negative Romberg sign. Coordination and gait normal. *
Reflex Scores:
**** Tricep reflexes are 2+ on the right side and 2+ on the left side.
**** Bicep reflexes are 2+ on the right side and 2+ on the left side.
**** Brachioradialis reflexes are 2+ on the right side and 2+ on the left side.
**** Patellar reflexes are 3+ on the right side and 3+ on the left side.
**** Achilles reflexes are 3+ on the right side and 3+ on the left side.

Assessment and Plan
* Episodes of altered consciousness-
CBC,CMP, TSH normal
EKG shows normal sinus rhythm
UA normal
Urine HCG negative
CT of head normal.
Discussed with patient 24 hour BP monitoring/holter monitor.* She wants to consult with her family and possibly her PCP at Kaiser.* She will let me know if she wishes me to facilitate further testing.
**
*Orders
* *Normal Orders This Visit
* CBC WITH AUTO DIFF
* COMPRE METAB PANEL
* ECG ROUTINE ECG W/LEAST 12 LDS W/I&R
* THYROID STIMULATING HORMONE (TSH)
* UA DIP NON-AUTO W/O MICRO (POCT) 81002
* UNLISTED CT PROCEDURE
* URINALYSIS, COMPLETE W/REFLEX TO CULTURE
* URINE PREGNANCY TEST, VISUAL COLOR COMPARISON METHODS


Second Patient:(Provider bills 99204, I score 99202)

HPI Patient is a 39 year old female is here for stomach pain and heart twinges.
Stomach pain
-started a week ago
-describes it as a stomach ach *
-is more intense an hour or two after she has eating
-the last couple days it is hurting even when she is not eating *
-has been trying to make her diet different to help with the pain
Some nausea.* No heartburn.* Feels like her gallbladder may be an issue.

-since February she feels like she might be getting sick and has a dry cough.* No fever, chills.* No SOB.* No asthma.* Nonsmoker. *

Heart twinges
-started around March *
-has gotten more frequent and duration is more longer
-happening every day and multiple times *
-has gotten worse in the last week
-when leaning forward or to leans to her left side
-the pain is mostly in her chest or on her left side of her chest
-the pain will radiate to her left arm *
-have noticed that the fingers on her left hand will get numb
-she is also having a back ache and tooth ache after a twinge

Twinge of pain in left anterior chest-just at sternum.* Lasts seconds.* Feels like a "pinch".* No pattern or trigger.* Can occur multiple times a day.* Not dependent on position, activity.* Resolves spontaneously.

Some aching pain, upper left anterior chest.* No trigger or pattern.* Can last longer and she thinks she may experience some jaw and left arm symptoms.* Not definitively related to activity.

Has had similar symptoms before.* Not as frequent as now.* Last evaluation was 2 years ago with cardiac echo and holter monitor.* Both were normal/negative.

Indicates that she is an anxious person and is very anxious about these symptoms.

-was told to have pre diabetes and was put on Metformin and she has run out and stop taking it *
-was said to have high blood pressure and was taking fish oil for it and that ran out so she stop taking it in May

-also is having spotting and cramping this week.* Has large uterine fibroid per personal report.* Has gyn appt. In early August.

Review of Systems
Constitutional: Positive for malaise/fatigue. Negative for fever and chills.
Respiratory: Positive for shortness of breath.*
Cardiovascular: Positive for chest pain.
Gastrointestinal: Positive for nausea, abdominal pain and constipation. Negative for vomiting and diarrhea.
Genitourinary: Negative for dysuria, urgency and frequency.
Neurological: Positive for headaches. Negative for dizziness and weakness.

Objective


Vitals
There were no vitals filed for this visit.

There is no height or weight on file to calculate BMI.
Normalized BMI data available only for age 2 to 20 years.


Physical Exam
Constitutional: She appears well-developed.
HENT:
Right Ear: Tympanic membrane and ear canal normal.
Left Ear: Tympanic membrane and ear canal normal.
Eyes: Conjunctivae are normal. Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. No thyromegaly present.
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: Effort normal and breath sounds normal. She has no wheezes. She has no rales. She exhibits no tenderness.
Abdominal: There is no hepatosplenomegaly. There is tenderness in the epigastric area.

Assessment and Plan
* Chest/abdominal discomfort-
EKG normal

CBC showed mild anemia (chronic recurrent per patient)
CMP normal
Lipase normal
TSH normal

Urged a trial of Prilosec/Zantac daily x 2 weeks
Reassurance, but strongly suggested PCP visit when she returns home. (she has appt 8/2).
RTC or ER if worsening or concerning symptoms
*

*Orders
* *Normal Orders This Visit
* ASSAY OF LIPASE
* CBC WITH AUTO DIFF
* COMPRE METAB PANEL
* ECG ROUTINE ECG W/LEAST 12 LDS TRCG ONLY W/O I&R
* THYROID STIMULATING HORMONE (TSH)
*

Thanks for your help!!!
 
Messages
811
Best answers
0
I also say 99203 for both. I think the major hang-up is the PFSH component.

One thing I noted was that on the first patient, there's documentation about previous visits, but how that be if the patient is new?
 
Top