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NEED HELP!!! How do you code this E/M?

  1. Default NEED HELP!!! How do you code this E/M?
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    Nurse Note: Patient is a 7 year old female who present today because Singulair was not approved and she is to try a nasal spray first. She is feeling good but sniffles constantly.Chief Complaint: Patient presents with allergic rhinitis. HPI: Allergic rhinitis. Insurance company will not cover the Singulair. She has been on Claritin for a while but not completely taking care of symptoms. “She snots a lot”. Patient feeling well. Taking medication as prescribed, see flow sheet. Present for years. Onset was gradual. Has worsened since onset. Occurs seasonally. Patient unaware of any aggravating factors. No alleviating factors. Symptom does not disturb sleep. ROS: Const: Denies fatigue, fever and loss of appetite. General health stated as good. Eyes: Denies discharge. ENMT: Nose and Sinuses: Reports congestion, nasal discharge, and mouth breathing. Mouth and Throat: Denies mouth and throat symptoms. CV: Denies chest pain, cough and fatigue. GI: Reports nausea, but denies constipation and diarrhea.Current Meds: Loratadine 10mg, Polyviflor 1mg Allergies: NKDAPast Medical History: Unremarkable. Family History: Hypertension, MI, Breast Cancer, and Colon cancer.Social History: Patient lives with both parents and two brothers. The home is smoke free. Household pets include 2 cats and 2 dogs.Objective: BP: 102/58, Pulse: 80, Temp: 97.1, Resp: 24, Ht: 48.5”, Wt: 54lbs, BMI: 16.1.Exam: Const: Appears healthy and cooperative. Weighs within the normal range for stated age. No signs of acute distress present. ENMT: Auditory canals are patent. Tympanic membranes translucent, with good landmarks bilaterally. Nasal mucosa shows moistness and normal color, but no discharge. No discoloration or swelling of the turbinates. Oral mucosa: pink and moist. Tonsils appear normal. Resp: Respiration rate is normal. No wheezing. CV: Rate is within normal range. Rhythm is regular. Skin: Warm and dry with no rash. No acne.Assessment and Plan: Allergic Rhinitis. Take Nasonex 10mcg/act use 1 spray in each nostril daily. Continue the Loratadine 10mg 1 po qd prn. Follow up if symptoms persist and for scheduled WCC.

  2. Default
    Quote Originally Posted by jwschroeterjr@gmail.com View Post
    Nurse Note: Patient is a 7 year old female who present today because Singulair was not approved and she is to try a nasal spray first. She is feeling good but sniffles constantly.Chief Complaint: Patient presents with allergic rhinitis. HPI: Allergic rhinitis. Insurance company will not cover the Singulair. She has been on Claritin for a while but not completely taking care of symptoms. “She snots a lot”. Patient feeling well. Taking medication as prescribed, see flow sheet. Present for years. Onset was gradual. Has worsened since onset. Occurs seasonally. Patient unaware of any aggravating factors. No alleviating factors. Symptom does not disturb sleep. ROS: Const: Denies fatigue, fever and loss of appetite. General health stated as good. Eyes: Denies discharge. ENMT: Nose and Sinuses: Reports congestion, nasal discharge, and mouth breathing. Mouth and Throat: Denies mouth and throat symptoms. CV: Denies chest pain, cough and fatigue. GI: Reports nausea, but denies constipation and diarrhea.Current Meds: Loratadine 10mg, Polyviflor 1mg Allergies: NKDAPast Medical History: Unremarkable. Family History: Hypertension, MI, Breast Cancer, and Colon cancer.Social History: Patient lives with both parents and two brothers. The home is smoke free. Household pets include 2 cats and 2 dogs.Objective: BP: 102/58, Pulse: 80, Temp: 97.1, Resp: 24, Ht: 48.5”, Wt: 54lbs, BMI: 16.1.Exam: Const: Appears healthy and cooperative. Weighs within the normal range for stated age. No signs of acute distress present. ENMT: Auditory canals are patent. Tympanic membranes translucent, with good landmarks bilaterally. Nasal mucosa shows moistness and normal color, but no discharge. No discoloration or swelling of the turbinates. Oral mucosa: pink and moist. Tonsils appear normal. Resp: Respiration rate is normal. No wheezing. CV: Rate is within normal range. Rhythm is regular. Skin: Warm and dry with no rash. No acne.Assessment and Plan: Allergic Rhinitis. Take Nasonex 10mcg/act use 1 spray in each nostril daily. Continue the Loratadine 10mg 1 po qd prn. Follow up if symptoms persist and for scheduled WCC.

    I am going to assume this is a "new patient office visit."

    Chief Complaint: allergic rhinitis

    HPI: Quality (snots a lot), Assoc (Patient feeling well), Mod Fac (She has been on Claritin for a while), Duration (present for years)

    ROS: Const, Eyes, ENMT, CV, GI = 2-9

    PFSH: Past Medical History: Unremarkable (Thats if your medicare carrier accepts this term, ours does not). Family History: Hypertension, MI, Breast Cancer, and Colon cancer.Social History: Patient lives with both parents and two brothers. The home is smoke free. Household pets include 2 cats and 2 dogs.

    Exam: Const, ENMT, Resp, CV, Skin = 95' Detailed exam

    MDM:

    Problem points = 3 (new problem to examiner no additional work up planned)
    Level of risk = Moderate (pres. drug mgmt)
    Data = None
    ------------------------
    Moderate Medical Decision Making

    CC: Yes
    HPI: Extended
    PFSH: Comprehensive
    ROS: Extended
    Exam: Detailed
    MDM: Moderate
    _____________
    99204

    I hope this helps, have a great afternoon!

  3. Default
    Quote Originally Posted by 021402 View Post
    I am going to assume this is a "new patient office visit."

    Chief Complaint: allergic rhinitis

    HPI: Quality (snots a lot), Assoc (Patient feeling well), Mod Fac (She has been on Claritin for a while), Duration (present for years)

    ROS: Const, Eyes, ENMT, CV, GI = 2-9

    PFSH: Past Medical History: Unremarkable (Thats if your medicare carrier accepts this term, ours does not). Family History: Hypertension, MI, Breast Cancer, and Colon cancer.Social History: Patient lives with both parents and two brothers. The home is smoke free. Household pets include 2 cats and 2 dogs.

    Exam: Const, ENMT, Resp, CV, Skin = 95' Detailed exam

    MDM:

    Problem points = 3 (new problem to examiner no additional work up planned)
    Level of risk = Moderate (pres. drug mgmt)
    Data = None
    ------------------------
    Moderate Medical Decision Making

    CC: Yes
    HPI: Extended
    PFSH: Comprehensive
    ROS: Extended
    Exam: Detailed
    MDM: Moderate
    _____________
    99204

    I hope this helps, have a great afternoon!

    Looking this over I made a very big boo boo this would be 99203 based on less than 10 systems reviewed. My apologies

  4. #4
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    Grand Rapids, MI
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    If this is a Nurse note (RN) then the most you can charge is 99211.

  5. Default
    Quote Originally Posted by abc1099 View Post
    If this is a Nurse note (RN) then the most you can charge is 99211.
    I agree with the last post, if this indeed was a nurse visit.

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