Jenetteis
Networker
I need some advice. I am wondering if this is still billable as a preventive/well woman visit 99395 even though the provider doesn't document a comprehensive ROS, just says, "ROS as noted in the HPI". Thank you for any advice.
HPI
Annual Premenopausal (UEHRC)
Reported by patient.
Patient Relationship to Practice: new patient
Current Medical History: no active medical problems
Relevant Family History: family history of ovarian cancer; family history of uterine cancer; no family history of breast cancer; no family history of colon cancer; no family history of blood clots/DVT
Menstrual History: Frequency of Menses: monthly
Contraceptive Method: nothing; satisfied
Sexually Active: Yes:
STI Screen: desires
Health/Prevention: Exercise: no; Multivitamins: no; Vitamin D: no; Adequate Calcium Intake: no; Breast Self Exam: no; Seat Belt Use: yes; Safe Sex: yes; Tobacco Use: no
Mammogram: not applicable
Pap Smear +/- HPV Cotesting: due
Colonoscopy: not applicable
Patient has: Primary Care Physician: yes
33 yo female presents to the office for her WWE/PAP/STI testing. Pt reports a h/o asthma (controlled with medication) and stress incontinence. Pt states she has done kegal exercises, use of kegel ball for help with no resolution. Denies any other concerns today. LMP 5/14/20.
ROS
ROS as noted in the HPI
Physical Exam
Patient is a 33-year-old female.
Chaperone: Chaperone: present.
Constitutional: *General Appearance: obese.
Head: Head: normocephalic.
Neck: *ROM normal ROM. *Thyroid: no enlargement or nodules and non-tender.
Lymph Nodes: *Palpation: normal.
Cardiovascular: *Auscultation: RRR and no murmur. *Peripheral Vascular: no varicosities or edema and pedal pulses intact.
Lungs: *Respiratory Effort: no accessory muscle usage or intercostal retractions. *Auscultation: no wheezing, rales/crackles, or rhonchi and clear to auscultation. Inspection: normal and normal respiratory rate.
*Breast: Bilateral: no tenderness, skin changes, abnormal nipple secretions, or masses palpable and nipple appearance: normal and fibrocystic/dense breast(s) bilateral. Right Breast: normal. Left Breast: normal.
Back: Appearance normal. Palpation no costovertebral angle tenderness.
Abdomen: *Inspection/Palpation/Auscultation: no tenderness, rebound, guarding, hepatomegaly, splenomegaly, or masses palpable and non-distended, soft, and normal bowel sounds. *Hernia: none palpated.
Female Genitalia: Vulva: no erythema, excoriation, discoloration, lesions, vesicles, atrophy, masses, swelling, or tenderness and normal. Mons: no erythema, excoriation, atrophy, lesions, masses, swelling, tenderness, or vesicles/ ulcers and normal. Clitoris: no erythema, excoriation, discoloration, lesions, vesicles, atrophy, masses, swelling, or tenderness and normal. Labia Majora: no erythema, excoriation, atrophy, discoloration, lesions, masses, swelling, tenderness, or vesicles/ ulcers and normal. Labia Minora: no erythema, excoriation, atrophy, discoloration, lesions, vesicles, masses, swelling, or tenderness and normal. Introitus: normal. Bartholin's Gland: normal. *Vagina: no discharge, erythema, atrophy, lesions, ulcers, swelling, masses, tenderness, prolapse, or blood present and normal. *Cervix: no lesions, discharge, bleeding, or cervical motion tenderness and grossly normal and sample taken for a Pap smear. *Uterus: normal size and contour and midline, mobile, non-tender, and no uterine prolapse. *Urethral Meatus/ Urethra: no discharge, masses, or tenderness and normal meatus and well supported urethra. *Bladder: non-distended, non-tender, and no palpable mass. *Adnexa/Parametria: no tenderness or mass palpable.
Rectum: *Anus & Perineum: normal perineum and perianal skin and no hemorrhoids or anal fissure. *Digital Rectal: no hemorrhoids or masses and sphincter tone normal and normal rectovaginal septum.
Extremities: Legs: normal and no calf tenderness. Arms: normal. Pulses: normal and pulses present.
Skin: *Appearance: no rashes or lesions.
Neurological System: Impressions: motor: no deficits and sensory: no deficits. Reflexes: normal.
Psychiatric: *Orientation: to person, place, and time. *Mood and Affect: normal mood and affect and active and alert.
HPI
Annual Premenopausal (UEHRC)
Reported by patient.
Patient Relationship to Practice: new patient
Current Medical History: no active medical problems
Relevant Family History: family history of ovarian cancer; family history of uterine cancer; no family history of breast cancer; no family history of colon cancer; no family history of blood clots/DVT
Menstrual History: Frequency of Menses: monthly
Contraceptive Method: nothing; satisfied
Sexually Active: Yes:
STI Screen: desires
Health/Prevention: Exercise: no; Multivitamins: no; Vitamin D: no; Adequate Calcium Intake: no; Breast Self Exam: no; Seat Belt Use: yes; Safe Sex: yes; Tobacco Use: no
Mammogram: not applicable
Pap Smear +/- HPV Cotesting: due
Colonoscopy: not applicable
Patient has: Primary Care Physician: yes
33 yo female presents to the office for her WWE/PAP/STI testing. Pt reports a h/o asthma (controlled with medication) and stress incontinence. Pt states she has done kegal exercises, use of kegel ball for help with no resolution. Denies any other concerns today. LMP 5/14/20.
ROS
ROS as noted in the HPI
Physical Exam
Patient is a 33-year-old female.
Chaperone: Chaperone: present.
Constitutional: *General Appearance: obese.
Head: Head: normocephalic.
Neck: *ROM normal ROM. *Thyroid: no enlargement or nodules and non-tender.
Lymph Nodes: *Palpation: normal.
Cardiovascular: *Auscultation: RRR and no murmur. *Peripheral Vascular: no varicosities or edema and pedal pulses intact.
Lungs: *Respiratory Effort: no accessory muscle usage or intercostal retractions. *Auscultation: no wheezing, rales/crackles, or rhonchi and clear to auscultation. Inspection: normal and normal respiratory rate.
*Breast: Bilateral: no tenderness, skin changes, abnormal nipple secretions, or masses palpable and nipple appearance: normal and fibrocystic/dense breast(s) bilateral. Right Breast: normal. Left Breast: normal.
Back: Appearance normal. Palpation no costovertebral angle tenderness.
Abdomen: *Inspection/Palpation/Auscultation: no tenderness, rebound, guarding, hepatomegaly, splenomegaly, or masses palpable and non-distended, soft, and normal bowel sounds. *Hernia: none palpated.
Female Genitalia: Vulva: no erythema, excoriation, discoloration, lesions, vesicles, atrophy, masses, swelling, or tenderness and normal. Mons: no erythema, excoriation, atrophy, lesions, masses, swelling, tenderness, or vesicles/ ulcers and normal. Clitoris: no erythema, excoriation, discoloration, lesions, vesicles, atrophy, masses, swelling, or tenderness and normal. Labia Majora: no erythema, excoriation, atrophy, discoloration, lesions, masses, swelling, tenderness, or vesicles/ ulcers and normal. Labia Minora: no erythema, excoriation, atrophy, discoloration, lesions, vesicles, masses, swelling, or tenderness and normal. Introitus: normal. Bartholin's Gland: normal. *Vagina: no discharge, erythema, atrophy, lesions, ulcers, swelling, masses, tenderness, prolapse, or blood present and normal. *Cervix: no lesions, discharge, bleeding, or cervical motion tenderness and grossly normal and sample taken for a Pap smear. *Uterus: normal size and contour and midline, mobile, non-tender, and no uterine prolapse. *Urethral Meatus/ Urethra: no discharge, masses, or tenderness and normal meatus and well supported urethra. *Bladder: non-distended, non-tender, and no palpable mass. *Adnexa/Parametria: no tenderness or mass palpable.
Rectum: *Anus & Perineum: normal perineum and perianal skin and no hemorrhoids or anal fissure. *Digital Rectal: no hemorrhoids or masses and sphincter tone normal and normal rectovaginal septum.
Extremities: Legs: normal and no calf tenderness. Arms: normal. Pulses: normal and pulses present.
Skin: *Appearance: no rashes or lesions.
Neurological System: Impressions: motor: no deficits and sensory: no deficits. Reflexes: normal.
Psychiatric: *Orientation: to person, place, and time. *Mood and Affect: normal mood and affect and active and alert.