NESmith
Expert
CC-New patient to establish,referral for mammogram.
HPI-Pt is a 62 yr old female. New pt.to establish care. HTN/High chol/patient on Weight Wathcers. Pt having breast pain on the rt side, last mammogram was 2 yrs agao. last labs 6 months ago. pt wants Wellness visit.
Past Medical/Surgical Hx
Reported Hx:
Pregnancy: Gravida 2
Diagnosis HX:
Hypertension
Hyperlipidema
Therapeutic Hx:
Cholecystectomy
Hysterectomy
Social Hx:
Behavioral: Caffeine use 2 cups of coffee daily. Not smoking. A previous hx of smoking quit 6 yrs ago.
Alcohol: Alcohol use socially
Drug Use: Not using drugs
Habits: Good exercise habits
Work: retires
matial: Currently married
Functional: No physical disability
ROS:
Cariovascular: No symptoms
Pulmonary: No symptoms
GI: No symptoms.
Pertinebt positives and negatives as stated in the HPI; otherwise negative in all 14 systems as reviewed with the patient.
Physical Findings:
Vitals
Heneral Appearance:
Oriented to time, place ad person in no acute distress.
Neck:
Suppleness: The nek demonstrated no decrease in suppleness.
Thyroid: The thyroid showed no abnormalities.
Lungs:
Normal breath sounds/voice sounds, no wheezing was heard, no rhonchi were heard, and no rales/crackles were heard.
Cariovascular:
Heart Rate and Rhythm: Heasrt rate and rhythm normal
Heart Sounds: S1 nomral and the S2 was normal
No murmurs were heard.
Edema not present.
Neurological:
Speech was normal
Gait and Stance were normal.
Psych: Affect was normal
Skin: Skin temperature was normal.
Assessment:
Pain in Rt breast-Possible M/S as pt started exercise and diet program.
last mamogram was 2 yrs ago
Normal routine Hx and Physical
Essential Hypertension-last labs was 6 months ago. Ordered. Atenolo/HCTZ 50/25 g q day request 90 days refill
Hyperlipidema-labs orderd Lovastatin 20 mg Q eve. refilled per pt request
Plan:
Mammogram ordered. labs ordered
Dx HTN/High Chol
OK, after all of that my question is; would you code this as a Preventive or New Patient. My provider did both. I don't feel this is correct. Thanks for your help as always.
HPI-Pt is a 62 yr old female. New pt.to establish care. HTN/High chol/patient on Weight Wathcers. Pt having breast pain on the rt side, last mammogram was 2 yrs agao. last labs 6 months ago. pt wants Wellness visit.
Past Medical/Surgical Hx
Reported Hx:
Pregnancy: Gravida 2
Diagnosis HX:
Hypertension
Hyperlipidema
Therapeutic Hx:
Cholecystectomy
Hysterectomy
Social Hx:
Behavioral: Caffeine use 2 cups of coffee daily. Not smoking. A previous hx of smoking quit 6 yrs ago.
Alcohol: Alcohol use socially
Drug Use: Not using drugs
Habits: Good exercise habits
Work: retires
matial: Currently married
Functional: No physical disability
ROS:
Cariovascular: No symptoms
Pulmonary: No symptoms
GI: No symptoms.
Pertinebt positives and negatives as stated in the HPI; otherwise negative in all 14 systems as reviewed with the patient.
Physical Findings:
Vitals
Heneral Appearance:
Oriented to time, place ad person in no acute distress.
Neck:
Suppleness: The nek demonstrated no decrease in suppleness.
Thyroid: The thyroid showed no abnormalities.
Lungs:
Normal breath sounds/voice sounds, no wheezing was heard, no rhonchi were heard, and no rales/crackles were heard.
Cariovascular:
Heart Rate and Rhythm: Heasrt rate and rhythm normal
Heart Sounds: S1 nomral and the S2 was normal
No murmurs were heard.
Edema not present.
Neurological:
Speech was normal
Gait and Stance were normal.
Psych: Affect was normal
Skin: Skin temperature was normal.
Assessment:
Pain in Rt breast-Possible M/S as pt started exercise and diet program.
last mamogram was 2 yrs ago
Normal routine Hx and Physical
Essential Hypertension-last labs was 6 months ago. Ordered. Atenolo/HCTZ 50/25 g q day request 90 days refill
Hyperlipidema-labs orderd Lovastatin 20 mg Q eve. refilled per pt request
Plan:
Mammogram ordered. labs ordered
Dx HTN/High Chol
OK, after all of that my question is; would you code this as a Preventive or New Patient. My provider did both. I don't feel this is correct. Thanks for your help as always.