Wiki Please Advise Level of this Service

[vikas.maheshwari]

Chief Complaint: Follow-up

HPI: She still complains of fatigue. she did lose a little bit. She
doesn't notice dramatic help with the phentermine +/- on the T3. She
has been noticing little things of stumbling, mixing up words, etc.
When writing, she is misspelling. she was always good at spelling. she
says it is almost like a dyslexic person, but she knows she doesn't
have that because she has never had trouble before. She did the rest
to eat before to see if it was hypoglycemia. She has no Family history
of ADD. I gave her the little test. She Scored 25. Over 2/3 of it was
in the inattention sector, 18, and the rest was in hyperactivity. We
are going to give it a trial. She's home for a few weeks, so it won't
be as good of a trial as when she is back at school, but she has got a
big paper.

Exam: Wt. 144 lbs. temp: 98.3

Plan:

Follow-up in the first week of January if she wants to continue. If
the Addreall 10's make her more nervous and anxious. That's a negative
test and I told her to forget it.

Just keep the T3 as is for now. Do one thing at a time.

 

[kumeena]

I feel like it is level 2 (Est pt) 2keys

 

[LLovett]

What is this patient being seen for? What is the diagnosis? I wouldn't bill this out until those 2 questions are clarified with an addendum by the provider.

As far as just leveling this supports a 2 if it is an established problem stable, 3 if the problem is getting worse but I honestly can't tell based on this note, it is too incomplete.

Just my opinion,

Laura, CPC, CEMC

 

[vikas.maheshwari]

This is a followup for weight loss program.

 

[Mjones7]

I would have to code this as a 99212 however, with an addendum, providing a few more details, this could easily be a level three visit.

 

[MnTwins29]

Even though it is a F/U to a weight loss program, there still needs to be some type of diagnosis (obesity, etc.) for a CC/primary diagnosis. The documentation you gave doesn't state that. I too would need a few more details to give an honest assessment to determine the level.

 

[vikas.maheshwari]

most of the time we have hypothyroidism patient or obesity patient. Can be take these ICD from earlier DOS?????

 

[MnTwins29]

most of the time we have hypothyroidism patient or obesity patient. Can be take these ICD from earlier DOS?????

If the MD writes it in the progress note, such as "f/u obesity", then yes, that is fine. Each visit should have a diagnosis documented and can "stand" on it's own.