maine4me
Guru
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
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