Here is what the document looks like. I removed all Provider and Patient information
This is not a good document and we are working with our provider on this. Please tell me what you think.
Also my understanding with HTN and CKD it that provider needs to make that connection in order for that 403 coding to be use. I dont beleive the provider made any connection in this document.
PCP:
Visit Type: Follow-up
Patient stated Chief Complaint to Nurse: 68 year old Male comes in today for: f/u kidney disease. Lab work was not done.
F/u HTN management, BP is better today, lost some weight.
Chief complaint obtained by:
Reviewed changes to medication list with patient
Current Allergy:
* NSAIDS CYCLOOXYGENASE INHIBITOR TYPE (Critical)
* HONEY BEE VENOM (Critical)
* SHELLFISH (Critical)
Reviewed allergy and adverse reaction changes with patient
Entered weight: 220 lb.
Calculated Wt: 220 lb.
Weight in Kg: 100.00
Ht: 69 in.
Height in cm: 175.26
BMI: 32.61
BSA: 2.15
Weight Change:-2
Temperature: 97.81
Temp site: oral
Pulse rate: 67
Respirations: 20
Blood Pressure: Standard
Blood Pressure #1: 132 /70 mm Hg Cuff Size: Medium (Regular Adult Size) Site: left arm Entered By: Yuliya L Smart, CMA on December 16, 2014 2:50 PM
O2 Sat %: 98
On: Room Air
Vitals entered by
Chief Complaint/History of Present Illness/ROS: Here for Kidney disease f/u
Forgot to get blood drawn today
Needs refill powder
Having some tarry stools, off and on for a week
Stomach feeling a little bloated.
Will double the omep
Has had upper endoscopy in the past several months by hx.
Feeling pretty well, no other complaints except for the usual back pain/sciatica. Still working outside, was getting in wood this morning before it started raining.
Substance Risk Factors
Nicotine Use: current every day smoker
Type of Nicotine: Chew
Year Started: 2008
Counseled to quit/cut down: yes
Alcohol use? quit
Date quit alcohol: 1990
Other Risk Factors
Have you been to the Emergency Room or Hospital since your last office visit? no
Review of Systems
General
Denies fever and chills.
CV
Denies chest pain or discomfort.
Resp
Denies shortness of breath.
MS
Complains of joint pain.
Physical Exam
General:
well developed, well nourished, in no acute distress.
Lungs:
breathing well
Heart:
Regular rate and rhythm, normal S1, S2 without murmurs, rubs, or gallops
Abdomen:
normal bowel sounds; no hepatosplenomegaly, no ventral, umbilical hernias or masses noted. Mild epigastric tenderness
Extremities:
no clubbing, cyanosis, edema, or deformity noted
Psych:
alert and cooperative; normal mood and affect; normal attention span and concentration.
Impression & Recommendations:
Problem # 1: Chronic kidney disease stage V (ICD-585.3) (ICD10-N18.3)
labs today, same meds.
Problem # 2: Hyperkalemia (ICD-276.7) (ICD10-E87.5)
labs
Problem # 3: GERD (ICD-530.81) (ICD10-K21.9)
His updated medication list for this problem includes:
Omeprazole 20 Mg Cpdr (Omeprazole) ..... 1 tab twice a day for gerd
double the omeprazole
Problem # 4: Hypertension (ICD-401.9) (ICD10-I10)
His updated medication list for this problem includes:
Minoxidil 10 Mg Tabs (Minoxidil) ..... 1 tablet by mouth daily
Metoprolol Tartrate 100 Mg Tabs (Metoprolol tartrate) ..... 1 tablet by mouth. twice a day
Furosemide 20 Mg Tabs (Furosemide) ..... 1 pill monday, wed, friday. fill on request.
Catapres 0.3 Mg Tabs (Clonidine hcl) ..... 1 tablet by mouth. twice a day
Medications Added to Medication List This Visit:
1) Omeprazole 20 Mg Cpdr (Omeprazole) .... 1 tab twice a day for gerd
Patient Instructions
double the omeprazole
Labs today
same meds for now
will call if we need to change meds.
Renal f/u tomorrow.
30 days. brunk 15 min. labs.
Clinical Visit Summary Handout Printed
Prescriptions:
OMEPRAZOLE 20 MG CPDR (OMEPRAZOLE) 1 tab twice a day for GERD #60[capsule] x 5
Entered and Authorized by:
Electronically signed by: on 12/16/2014
Method used: Electronically to
B-12 1000 MCG CAPS (CYANOCOBALAMIN) One tab daily #30[capsule] x 5
Entered and Authorized by:
Electronically signed by: on 12/16/2014
Method used: Electronically to
SODIUM POLYSTYRENE SULFONATE POWD (SODIUM POLYSTYRENE SULFONATE) 30 ml (One ounce) 5 days a week for potassium. Fill on request. #1 bottle[bottle] x 5
Entered and Authorized by:
Electronically signed by: on 12/16/2014
Method used: Electronically to