My provider wants to code a 99215 for this visit but in my review the documentation is lacking a Review of Systems which would drop the coding significantly. Am I overlooking something?
Patient is a 32 year old female here for alternative medicine tx of her varied conditions and health issues. Se had been seeing Annika Maly MD and desires a different approach to her health. She has not felt any better for the past year. She is in the midst of her husband having left her. She has no appetite at the present. She reports having a lymph node near her appendix, after eating she feels "gross" so she has to eat slowly. She feels she is cleansing with the food that she eats at the present. She takes magnesium, D3, vit. C, and a prenatal multi. She gets dizzy with exercise and get to the point of blacking out sometimes. She has had scarlet fever and strep throat three times a year. She has not had mono. She is aware of her food allergies and watches her diet. She reports having had CFS in her teens and a history of kidney stones. She had chronic diarrhea when her husband first moved out. She reports firmer BMs now but only has a BM once a day every two days.She also reports having a BM twice a week is normal for her. She practices intermittent fasting and does not eat between 7 PM and 10 AM. She is allergic to wheat, gluten, eggs, turkey, tomatoes, cucumbers, avocado and sesame. She takes Shitake and Reishi as adaptogens. She is allergic to Silybum marianum, St John's Wort, Valerian. She experiences sleep problems for which she is now seeking help with WW clinic. We discussed her starting a cleanse for which she is amenable to but she does have limited finances.
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Patient Active Problem List
Diagnosis
• RAD (reactive airway disease)
• Nephrolithiasis
• Pre-conception counseling
• Depression
• Migraine with visual aura
• Microhematuria
• Abdominal pain
• Fibromyalgia
• Chronic interstitial cystitis
• Screening
• Back pain
• History of pineal cyst
• Cervical cancer screening
• Arteriovenous malformation
• Psychogenic nonepileptic seizure
• Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)
• Drug-induced constipation
• Chronic post-traumatic headache, not intractable
• Somatic symptom disorder
• Hyperthyroidism
• Anxiety
• Asthma
• Arteriovenous fistula (HCC-CMS)
• Neck pain
• Cough
• Chronic pain syndrome
• Dysfunctional uterine bleeding
• Fatigue
• Headache
• Paroxysmal supraventricular tachycardia (HCC-CMS)
• Pineal gland cyst
• Sprain of wrist
• Controlled substance agreement signed
• Intrinsic eczema
• Weakness of both third cranial nerves
• Vasovagal syncope
• Other insomnia
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Current Outpatient Prescriptions
Medication Sig Dispense Refill
• midodrine (PROAMATINE) 10 mg tablet Take 1 Tab by mouth every morning 40 Tab 1
• oxyCODONE (ROXICODONE) 5 mg tablet Take 1 Tab by mouth every 8 (eight) hours as needed for pain Not to exceed 2 tabs per week 24 Tab 0
• buprenorphine 15 mcg/hour ptwk Place 1 Patch onto the skin every 7 (seven) days 4 Patch 0
• famotidine (PEPCID) 20 mg tablet Take 1 Tab by mouth 2 (two) times daily 180 Tab 3
• lidocaine (LIDODERM) 5 % patch Place 1 Patch onto the skin once daily (every 24 hours) 30 Patch 0
• tiZANidine (ZANAFLEX) 2 mg tablet Take 1 Tab by mouth every 6 (six) hours as needed for muscle spasms 60 Tab 1
• hydrOXYzine HCl (ATARAX) 25 mg tablet Take 0.5-1 Tabs by mouth 3 (three) times daily as needed for anxiety 30 Tab 1
• ondansetron (ZOFRAN-ODT) 8 mg disintegrating tablet Take 0.5-1 Tabs by mouth 3 (three) times daily as needed for nausea 30 Tab 3
• drospirenone-e.estradiol-lm.FA (BEYAZ) 3-0.02-0.451 mg (24) (4) tab Take 1 Tab by mouth once daily - 90 day straight with skipping placebo week. 28 Tab 11
• promethazine (PHENERGAN) 25 mg tablet Take 0.5-1 Tabs by mouth every 6 (six) hours as needed for nausea 30 Tab 3
• silver sulfADIAZINE (SILVADENE) 1 % cream Apply topically once daily 20 g 0
• fluoride, sodium, (DENTAGEL) 1.1 % gel Place in mouth once daily Apply to toothbrush. Do not swallow. 56 g 3
• propranolol (INDERAL) 10 mg tablet TAKE 1 TABLET BY MOUTH 2 TIMES DAILY AS NEEDED FOR PALPITATIONS. 60 Tab 1
• pimecrolimus (ELIDEL) 1 % cream Apply topically 2 (two) times daily Apply as a thin film. 30 g 1
• citalopram (CELEXA) 10 mg tablet Take 0.5 Tabs by mouth every other day uptitrate to 5-10mg daily as tolerated 30 Tab 3
• clobetasol (TEMOVATE) 0.05 % cream Apply topically 2 (two) times daily Apply as a thin film to the affected area. 30 g 3
• lactulose (CHRONULAC) 10 gram/15 mL solution Take 15 mL by mouth once daily OK to take up to 60mL in a day. Titrate up slowly. Goal is 1 BM per day. 473 mL 3
• TURMERIC/TURMERIC EXT/PEPR EXT (TURMERIC-TURMERIC EXT-PEPPER) 500-3 mg cap Take by mouth * *
• INULIN (FIBER GUMMIES ORAL) Take by mouth. * *
• naloxone (NARCAN) 4 mg/actuation nasal spray Spray 4 mg into 1 nostril upon signs of opioid overmedication. Call 911. 1 Each 1
• ALBUTEROL INHL Inhale 2 Puffs into the lungs. * *
• EPINEPHrine (EPIPEN) 0.3 mg/0.3 mL injection Inject 0.3 mg into the muscle as needed for anaphylaxis. * *
• budesonide nasal (RHINOCORT-AQ) 32 mcg/actuation nasal spray Place 1 Spray into the nostril(s) once daily. 8.6 g 3
• PNV NO.122/IRON/FOLIC ACID (PRENATAL #122-IRON-FOLIC ACID ORAL) Take by mouth. * *
• Magnesium Oxide 500 mg tab Take 500 mg by mouth. * *
• potassium gluconate 550 mg (90 mg) tab Take by mouth. * *
• LACTOBACILLUS ACIDOPHILUS (ACIDOPHILUS ORAL) Take by mouth. * *
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No current facility-administered medications for this visit.
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Objective
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Vitals
Vitals:
* 02/08/19 1608
BP: 114/77
Pulse: 81
SpO2: 94%
*
R10.9 Abdominal pain, unspecified abdominal location (primary encounter diagnosis)
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G89.4 Chronic pain syndrome
*
R55 Vasovagal syncope
*
M79.7 Fibromyalgia
*
G47.09 Other insomnia
*
L20.84 Intrinsic eczema
*
Z71.9 Health counseling
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Assessment and Plan: Since Patient has so many health conditions and is only in the county for the next month or two I am referring her for IV therapy which will address her desire to "feel good now". I did advise she start taking "Liver Care" by Himalayan, an Ayurvedic herb combo as a gentle support for her liver and to support further cleansing of her system. I also gave her the contact for patient physician co-op, a non profit practitioner/insurance group in the PDX area so she can continue her care there.
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Patient Instructions
1. Liver Care by Himalayan. Follow directions on bottle.
*
Gave pt contact for non profit insurance group in PDX.
*
Total of 60 minutes was spent with the patient. Greater than 50% of the time was spent in counseling and coordination of care for the above diagnosis.
*
Start time: 4:00 PM
Stop time: 5:00 PM
Patient is a 32 year old female here for alternative medicine tx of her varied conditions and health issues. Se had been seeing Annika Maly MD and desires a different approach to her health. She has not felt any better for the past year. She is in the midst of her husband having left her. She has no appetite at the present. She reports having a lymph node near her appendix, after eating she feels "gross" so she has to eat slowly. She feels she is cleansing with the food that she eats at the present. She takes magnesium, D3, vit. C, and a prenatal multi. She gets dizzy with exercise and get to the point of blacking out sometimes. She has had scarlet fever and strep throat three times a year. She has not had mono. She is aware of her food allergies and watches her diet. She reports having had CFS in her teens and a history of kidney stones. She had chronic diarrhea when her husband first moved out. She reports firmer BMs now but only has a BM once a day every two days.She also reports having a BM twice a week is normal for her. She practices intermittent fasting and does not eat between 7 PM and 10 AM. She is allergic to wheat, gluten, eggs, turkey, tomatoes, cucumbers, avocado and sesame. She takes Shitake and Reishi as adaptogens. She is allergic to Silybum marianum, St John's Wort, Valerian. She experiences sleep problems for which she is now seeking help with WW clinic. We discussed her starting a cleanse for which she is amenable to but she does have limited finances.
*
Patient Active Problem List
Diagnosis
• RAD (reactive airway disease)
• Nephrolithiasis
• Pre-conception counseling
• Depression
• Migraine with visual aura
• Microhematuria
• Abdominal pain
• Fibromyalgia
• Chronic interstitial cystitis
• Screening
• Back pain
• History of pineal cyst
• Cervical cancer screening
• Arteriovenous malformation
• Psychogenic nonepileptic seizure
• Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)
• Drug-induced constipation
• Chronic post-traumatic headache, not intractable
• Somatic symptom disorder
• Hyperthyroidism
• Anxiety
• Asthma
• Arteriovenous fistula (HCC-CMS)
• Neck pain
• Cough
• Chronic pain syndrome
• Dysfunctional uterine bleeding
• Fatigue
• Headache
• Paroxysmal supraventricular tachycardia (HCC-CMS)
• Pineal gland cyst
• Sprain of wrist
• Controlled substance agreement signed
• Intrinsic eczema
• Weakness of both third cranial nerves
• Vasovagal syncope
• Other insomnia
*
*
Current Outpatient Prescriptions
Medication Sig Dispense Refill
• midodrine (PROAMATINE) 10 mg tablet Take 1 Tab by mouth every morning 40 Tab 1
• oxyCODONE (ROXICODONE) 5 mg tablet Take 1 Tab by mouth every 8 (eight) hours as needed for pain Not to exceed 2 tabs per week 24 Tab 0
• buprenorphine 15 mcg/hour ptwk Place 1 Patch onto the skin every 7 (seven) days 4 Patch 0
• famotidine (PEPCID) 20 mg tablet Take 1 Tab by mouth 2 (two) times daily 180 Tab 3
• lidocaine (LIDODERM) 5 % patch Place 1 Patch onto the skin once daily (every 24 hours) 30 Patch 0
• tiZANidine (ZANAFLEX) 2 mg tablet Take 1 Tab by mouth every 6 (six) hours as needed for muscle spasms 60 Tab 1
• hydrOXYzine HCl (ATARAX) 25 mg tablet Take 0.5-1 Tabs by mouth 3 (three) times daily as needed for anxiety 30 Tab 1
• ondansetron (ZOFRAN-ODT) 8 mg disintegrating tablet Take 0.5-1 Tabs by mouth 3 (three) times daily as needed for nausea 30 Tab 3
• drospirenone-e.estradiol-lm.FA (BEYAZ) 3-0.02-0.451 mg (24) (4) tab Take 1 Tab by mouth once daily - 90 day straight with skipping placebo week. 28 Tab 11
• promethazine (PHENERGAN) 25 mg tablet Take 0.5-1 Tabs by mouth every 6 (six) hours as needed for nausea 30 Tab 3
• silver sulfADIAZINE (SILVADENE) 1 % cream Apply topically once daily 20 g 0
• fluoride, sodium, (DENTAGEL) 1.1 % gel Place in mouth once daily Apply to toothbrush. Do not swallow. 56 g 3
• propranolol (INDERAL) 10 mg tablet TAKE 1 TABLET BY MOUTH 2 TIMES DAILY AS NEEDED FOR PALPITATIONS. 60 Tab 1
• pimecrolimus (ELIDEL) 1 % cream Apply topically 2 (two) times daily Apply as a thin film. 30 g 1
• citalopram (CELEXA) 10 mg tablet Take 0.5 Tabs by mouth every other day uptitrate to 5-10mg daily as tolerated 30 Tab 3
• clobetasol (TEMOVATE) 0.05 % cream Apply topically 2 (two) times daily Apply as a thin film to the affected area. 30 g 3
• lactulose (CHRONULAC) 10 gram/15 mL solution Take 15 mL by mouth once daily OK to take up to 60mL in a day. Titrate up slowly. Goal is 1 BM per day. 473 mL 3
• TURMERIC/TURMERIC EXT/PEPR EXT (TURMERIC-TURMERIC EXT-PEPPER) 500-3 mg cap Take by mouth * *
• INULIN (FIBER GUMMIES ORAL) Take by mouth. * *
• naloxone (NARCAN) 4 mg/actuation nasal spray Spray 4 mg into 1 nostril upon signs of opioid overmedication. Call 911. 1 Each 1
• ALBUTEROL INHL Inhale 2 Puffs into the lungs. * *
• EPINEPHrine (EPIPEN) 0.3 mg/0.3 mL injection Inject 0.3 mg into the muscle as needed for anaphylaxis. * *
• budesonide nasal (RHINOCORT-AQ) 32 mcg/actuation nasal spray Place 1 Spray into the nostril(s) once daily. 8.6 g 3
• PNV NO.122/IRON/FOLIC ACID (PRENATAL #122-IRON-FOLIC ACID ORAL) Take by mouth. * *
• Magnesium Oxide 500 mg tab Take 500 mg by mouth. * *
• potassium gluconate 550 mg (90 mg) tab Take by mouth. * *
• LACTOBACILLUS ACIDOPHILUS (ACIDOPHILUS ORAL) Take by mouth. * *
*
No current facility-administered medications for this visit.
*
*
*
Objective
*
Vitals
Vitals:
* 02/08/19 1608
BP: 114/77
Pulse: 81
SpO2: 94%
*
R10.9 Abdominal pain, unspecified abdominal location (primary encounter diagnosis)
*
G89.4 Chronic pain syndrome
*
R55 Vasovagal syncope
*
M79.7 Fibromyalgia
*
G47.09 Other insomnia
*
L20.84 Intrinsic eczema
*
Z71.9 Health counseling
*
*
Assessment and Plan: Since Patient has so many health conditions and is only in the county for the next month or two I am referring her for IV therapy which will address her desire to "feel good now". I did advise she start taking "Liver Care" by Himalayan, an Ayurvedic herb combo as a gentle support for her liver and to support further cleansing of her system. I also gave her the contact for patient physician co-op, a non profit practitioner/insurance group in the PDX area so she can continue her care there.
*
Patient Instructions
1. Liver Care by Himalayan. Follow directions on bottle.
*
Gave pt contact for non profit insurance group in PDX.
*
Total of 60 minutes was spent with the patient. Greater than 50% of the time was spent in counseling and coordination of care for the above diagnosis.
*
Start time: 4:00 PM
Stop time: 5:00 PM