Elund
Networker
The documentation:
How do we know that the MCV4 0.5 mL IM vaccine refers to 90619 specifically?
Also, why should we report 90461 (two units)?
Pediatric Clinic
Established Patient
Sex: M
AGE: 12
DATE OF SERVICE: 1/1/20XX
HISTORIAN: Mother
VISIT TYPE: Office visit
CHIEF COMPLAINT: Ear pain.
HISTORY OF PRESENT ILLNESS: This 12 year old male presents with ear pain that started 1 day ago. The pain is located in the right ear. The problem was severe. Symptoms are associated with exposure to secondhand smoke. Symptoms are not associated with recent URI/cold and repeated Q-Tip use. Denies aggravating factors. Awoke from sleep at 4:00 a.m. with right ear pain.
PHYSICAL EXAMINATION:
GENERAL: No acute distress, nourishment type is overweight, well developed.
VITAL SIGNS: Weight 209 pounds with BMI 28.34, 6'2 temperature 97.2
HEENT: Eyes: No injection. Ears: Right, unremarkable to inspection. Canal normal in caliber, no excessive cerumen, no drainage. Tympanic membrane bulging and effusion-moderate. Left, unremarkable to inspection. Canal normal in caliber, no excessive cerumen, no drainage. Normal tympanic membrane.
No mucosal abnormality. Normal teeth and gums with dental caries. Palate and uvula appear symmetric and normal. No tonsillar hypertrophy or exudates. No pharyngeal erythema or exudates or mucosal lesion.
MEDICATIONS: Added Amoxicillin 400 mg/5 mL take 10 mL orally every 12 hours for 10 days.
ALLERGIES: No known allergies. Reviewed, no changes.
IMMUNIZATIONS: Administered this visit: Influenza virus vaccine, intranasal #1, 0.2 mL nasally. Tdap 0.5 mL IM, MCV4 0.5 mL IM.
ASSESSMENT AND PLAN:
1. Acute suppurative otitis media without spontaneous rupture of right ear drum. Do abx and reassure.
2. Overweight. Should stop gaining weight. Ideal weight would be 190 for height of 62ins. Exercise!
3. Counseled parent on vaccination
Electronically signed by John Thompson, MD.
Established Patient
Sex: M
AGE: 12
DATE OF SERVICE: 1/1/20XX
HISTORIAN: Mother
VISIT TYPE: Office visit
CHIEF COMPLAINT: Ear pain.
HISTORY OF PRESENT ILLNESS: This 12 year old male presents with ear pain that started 1 day ago. The pain is located in the right ear. The problem was severe. Symptoms are associated with exposure to secondhand smoke. Symptoms are not associated with recent URI/cold and repeated Q-Tip use. Denies aggravating factors. Awoke from sleep at 4:00 a.m. with right ear pain.
PHYSICAL EXAMINATION:
GENERAL: No acute distress, nourishment type is overweight, well developed.
VITAL SIGNS: Weight 209 pounds with BMI 28.34, 6'2 temperature 97.2
HEENT: Eyes: No injection. Ears: Right, unremarkable to inspection. Canal normal in caliber, no excessive cerumen, no drainage. Tympanic membrane bulging and effusion-moderate. Left, unremarkable to inspection. Canal normal in caliber, no excessive cerumen, no drainage. Normal tympanic membrane.
No mucosal abnormality. Normal teeth and gums with dental caries. Palate and uvula appear symmetric and normal. No tonsillar hypertrophy or exudates. No pharyngeal erythema or exudates or mucosal lesion.
MEDICATIONS: Added Amoxicillin 400 mg/5 mL take 10 mL orally every 12 hours for 10 days.
ALLERGIES: No known allergies. Reviewed, no changes.
IMMUNIZATIONS: Administered this visit: Influenza virus vaccine, intranasal #1, 0.2 mL nasally. Tdap 0.5 mL IM, MCV4 0.5 mL IM.
ASSESSMENT AND PLAN:
1. Acute suppurative otitis media without spontaneous rupture of right ear drum. Do abx and reassure.
2. Overweight. Should stop gaining weight. Ideal weight would be 190 for height of 62ins. Exercise!
3. Counseled parent on vaccination
Electronically signed by John Thompson, MD.
How do we know that the MCV4 0.5 mL IM vaccine refers to 90619 specifically?
Also, why should we report 90461 (two units)?