Pre-op Exam

maine4me

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One of our family practice doctors saw a patient for a pre-op exam prior to a dental procedure. When I review the note I do not see any request from the dentist and or underlying conditions which would require a pre-op exam, unless the patient's mental retardation would warrant the exam.

The doctor coded the visit as follows:
99242 V72.84, 521.00
90471 V04.81
90656 V04.81

If there is no request for the pre-op exam then I have coded this visit as 99213. But I am stumped on the diagnosis for the E/M. The flu shot and administration are coded correctly.

I could you some advice. The note is below.

Assessment and Plan
Ambulatory Assessment/Plan:
Assessment/Plan:
V72.84 Pre Operative Physical Exam

Additional Plan Details:
Preop for dental procedure/cleaning - well 24 y/o female with MR. No changes to health hx. Normal baseline per parents. Depo for dysmenorrhea, otherwise no meds. Flu shot today. F/u with PCP for routine health issues/labs. F/u sooner prn.

HPI
HPI
Nursing Chief Complaint: Pre-op clearance - dental procedure - flu shot

Physician: 24 y/o female presents with parents for pre-op PE for dental check-up scheduled 11/15/11. Wisdom teeth pulled last year. No concerns. Parents deny changes to PMHx. ROS as per PE forms. No CP/SOB, no ST, cough. No behavior changes, no changes in po intake. No f/c. No rashes.
Vitals:
Height 62 in / 157.48 cm
Weight 224 lbs / 101.604698 kg
BSA 2.16 m2
BMI 41.0 kg/m2
Temperature 98.1 F / 36.72 C - Tympanic
Pulse 120
Blood Pressure 120/82, Right Arm
Personal Medical History
Personal medical history: Hx of: High cholesterol, Obesity, Mental Retardation, Other - MR with global developmental delay (unkown etiology)

Surgical History
Past Surgical History: Hx of: Other - teeth work - had general anesthesia, had eye surgery

Family History
Family history of CV disease: Positive:: FH coronary artery dis.

Social History
Social history:
Marital Status: Single
Household members: lives home with mom, dad, brother
Occupation: attends day program

Alcohol
Alcohol Intake: None

Substance Use
Substance use: Denies use

Problem List
-----

Past Medical/Surgical History
Chronic Problems:
MENTAL RETARDATION NOS
OBESITY, NOS
PURE HYPERCHOLESTEROLEM

EXAM
*****
*****
General: No acute distress. Pleasant, interactive, minimally verbal. HR recheck 90, RR 14.

HEENT: Sclera nonicteric, TM normal bilaterally, pharynx clear without exudate.

Neck: Supple, no lymphadenopathy. FROM.

Lungs: Clear to auscultation bilaterally.

Heart: Regular rate and rhythm without murmurs or rubs.

Abd: obese, soft, normal BS, no TTP.

Neuro: grossly intact.

Ext: FROM x 4 ext, strength 5/5. PPP, no c/c/e.

Skin: warm, dry, no lesions/rashes
 

Jenr0406

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Salisbury, MD
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CPT for preop clearance by PCP

Now that we are in 2016 I am hoping there is a better way to code a encounter w/ a PCP for a pre-procedural exam. There are no complaints that the pcp is treating. The surgery is for dislocated discs in neck. Diagnoses used is Z01818. What CPT should I be reviewing?
 
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