Verify office visit level

cnramsey

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Just double check this level. Provider has 99213 but I'm getting 99214. Just need a second opinion please. Thanks

Primary Provider:

CC: Diabetic ck , meds and , and cough.

History of Present Illness:
2 weeks of cough that is very harsh, thick phlegm, feels miserable. nasal drainage. no fever or chills.

blood sugars stable -fasting s 100-120 . no neuropathy.

smoker.

Vital Signs:

Patient Profile: Years Old
Height: 67 inches
Weight: 160 pounds
BMI: 25.15
BSA: 1.84
Temp: 96.1 degrees F tympanic
Pulse rate: 74 / minute
Pulse rhythm: regular
BP sitting: 120 / 70 (left arm)
Cuff size: regular

Vitals Entered By:

Physical Exam

General:
well developed, well nourished, in no acute distress.
Ears:
TM's intact and clear with normal canals with grossly normal hearing.
Nose:
red, irritated nares
Neck:
no masses, thyromegaly, or abnormal cervical nodes.
Lungs:
rhonci on left. no wheeze
Heart:
non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
Extremities:
trace edema
varicosities
Neurologic:
monfilament exam positive x 8.


Impression & Recommendations:

Problem # 1: PNEUMONIA (ICD-486)
clinically suspected pneumonia. hx of same
start levaquin. check inr on monday given interaction of quinolones with coumadin
f/u if not improving
Orders:
Hemogram (CBC no diff) (HGMP)

Her/His updated medication list for this problem includes:
Levaquin 500 Mg Tabs (Levofloxacin) ..... 1 po daily


Problem # 2: DIABETES MELLITUS, TYPE II, CONTROLLED (ICD-250.00)
blood sugars in good control. avandia to be pulled from market and will plan on going to lantus at that time
recheck a1c
Her/His updated medication list for this problem includes:
Enalapril Maleate 10 Mg Tabs (Enalapril maleate) ..... 1 po qd
Glucophage 1000 Mg Tabs (Metformin hcl) ..... 1 po bid
Avandia Tabs (Rosiglitazone maleate tabs) ..... Avandia 4 mg po qd

Orders:
Comprehensive Metabolic Panel (CMP)
Glycohemoglobin (GLHGB)


Problem # 3: HYPERLIPIDEMIA (ICD-272.4)
recheck lipids
Her/His updated medication list for this problem includes:
Gemfibrozil 600 Mg Tabs (Gemfibrozil) ..... One tab po bid

Orders:
Comprehensive Metabolic Panel (CMP)
Lipid Panel (9-12 Hour Fast) (LP)


Problem # 4: ATRIAL FIBRILLATION (ICD-427.31)
rate controlled
Her/His updated medication list for this problem includes:
Coumadin 5 Mg Tabs (Warfarin sodium) ..... One po tues - thurs- friday- sat-sun
Lanoxin 0.25 Mg Tabs (Digoxin) ..... 1 po qd
Warfarin Sodium 7.5 Mg Tabs (Warfarin sodium) ..... One po mon and wed


Medications Added to Medication List This Visit:
1) Levaquin 500 Mg Tabs (Levofloxacin) .... 1 po daily

Prescriptions:
LEVAQUIN 500 MG TABS (LEVOFLOXACIN)
 

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Messages
371
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Just double check this level. Provider has 99213 but I'm getting 99214. Just need a second opinion please. Thanks

Primary Provider:

CC: Diabetic ck , meds and , and cough.

History of Present Illness:
2 weeks of cough that is very harsh, thick phlegm, feels miserable. nasal drainage. no fever or chills.

blood sugars stable -fasting s 100-120 . no neuropathy.

smoker.

Vital Signs:

Patient Profile: Years Old
Height: 67 inches
Weight: 160 pounds
BMI: 25.15
BSA: 1.84
Temp: 96.1 degrees F tympanic
Pulse rate: 74 / minute
Pulse rhythm: regular
BP sitting: 120 / 70 (left arm)
Cuff size: regular

Vitals Entered By:

Physical Exam

General:
well developed, well nourished, in no acute distress.
Ears:
TM's intact and clear with normal canals with grossly normal hearing.
Nose:
red, irritated nares
Neck:
no masses, thyromegaly, or abnormal cervical nodes.
Lungs:
rhonci on left. no wheeze
Heart:
non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
Extremities:
trace edema
varicosities
Neurologic:
monfilament exam positive x 8.


Impression & Recommendations:

Problem # 1: PNEUMONIA (ICD-486)
clinically suspected pneumonia. hx of same
start levaquin. check inr on monday given interaction of quinolones with coumadin
f/u if not improving
Orders:
Hemogram (CBC no diff) (HGMP)

Her/His updated medication list for this problem includes:
Levaquin 500 Mg Tabs (Levofloxacin) ..... 1 po daily


Problem # 2: DIABETES MELLITUS, TYPE II, CONTROLLED (ICD-250.00)
blood sugars in good control. avandia to be pulled from market and will plan on going to lantus at that time
recheck a1c
Her/His updated medication list for this problem includes:
Enalapril Maleate 10 Mg Tabs (Enalapril maleate) ..... 1 po qd
Glucophage 1000 Mg Tabs (Metformin hcl) ..... 1 po bid
Avandia Tabs (Rosiglitazone maleate tabs) ..... Avandia 4 mg po qd

Orders:
Comprehensive Metabolic Panel (CMP)
Glycohemoglobin (GLHGB)


Problem # 3: HYPERLIPIDEMIA (ICD-272.4)
recheck lipids
Her/His updated medication list for this problem includes:
Gemfibrozil 600 Mg Tabs (Gemfibrozil) ..... One tab po bid

Orders:
Comprehensive Metabolic Panel (CMP)
Lipid Panel (9-12 Hour Fast) (LP)


Problem # 4: ATRIAL FIBRILLATION (ICD-427.31)
rate controlled
Her/His updated medication list for this problem includes:
Coumadin 5 Mg Tabs (Warfarin sodium) ..... One po tues - thurs- friday- sat-sun
Lanoxin 0.25 Mg Tabs (Digoxin) ..... 1 po qd
Warfarin Sodium 7.5 Mg Tabs (Warfarin sodium) ..... One po mon and wed


Medications Added to Medication List This Visit:
1) Levaquin 500 Mg Tabs (Levofloxacin) .... 1 po daily

Prescriptions:
LEVAQUIN 500 MG TABS (LEVOFLOXACIN)
I clearly get 99214

Exam: Detailed 95'

MDM

Problem pts: 4+
Level of risk: Moderate - Prescription drug management or one or more chronic illnesses w/ mild exacerbation
Work up pts: 1
_______________
Moderate MDM

Those components togther (exam + MDM) = 99214 in my opinion..:)
 
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