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?E/M level

  1. Default ?E/M level
    Exam Training Packages
    New patient provider has chosen 99204. When I work it up Im getting a 99203. Any advice..

    Visit Type: Acute Visit
    Primary Provider:

    CC: cough x 3 mos.

    History of Present Illness:
    pt states has had violent cough for three months, cannor remember what she/he has been tested for but labs always seem to be normal, very tired all the time

    Lives in Phoenix--has had cough for 3 months. Advair not helping. Sometimes coughs so hard she/he wets. Has had intermittant chronic bronchitis for several years--has been prescribed Advair discus-2 years ago. She/He says that she/he quit smoking 27 years ago. Has no sinus sx.
    Believes that she/he had PFTs in the past. Has tested negative for Valley Fever.

    Sputum is clear to brown--yesterday color changed. Has had slight temperature elevations. Appetie is fine. Not feeling ill.
    Has not had CT scan chest. Last chest xray was in January--for Bronchitis. Has not been told that she/he has bronchiectasis.
    Her/his spouse does smoke, but not near her/him.
    Has some allergies.

    Feels tired most of the time. Her/his ribs hurt from coughing so hard. Feels chest pressure most of the time. No new LE edema. Has no pain in her/his chest when she/he tries to exercise, just pressure from shortness of breath.
    Has not had pertussis update since childhood.

    Has started sleeping with 2 pillows. Short of breath primily from exertion.

    Past Medical History:
    Reviewed history and no changes required:
    Chronic bronchitis
    Bladder incontinence
    HTN
    Obesity--improved with lap band

    Past Surgical History:
    Reviewed history and no changes required:
    Lap band for obesity 2007
    Left knee total arthroplasty
    Hysterectomy in 1978

    Has not had screening colonoscopy


    Serial Vital Signs/Assessments:

    PEF PreRx PostRx
    Time O2 Sat O2 Type L/min L/min L/min By
    1:55 PM 95 % Room air 300
    3:42 PM 98 % Room air 350

    Family History:
    Reviewed history and no changes required:
    M-died age 49 from cervical and breast CA
    PGF died in 50s from MI
    F-died age 84 unknown cause

    Social History:
    Reviewed history and no changes required:
    Quit smoking 27 years ago.

    Risk Factors:

    Tobacco use: quit
    Year quit: 1984

    Review of Systems
    See HPI

    Vital Signs:

    Patient Profile: 68 Years Old
    Weight: 224.8 pounds
    O2 Sat: 95 %
    Temp: 98.0 degrees F tympanic
    Pulse rate: 67 / minute
    Pulse rhythm: regular
    Resp: 16 per minute
    BP sitting: 122 / 84 (left arm)
    Cuff size: large

    Pt. in pain? no

    Vitals Entered By:

    Physical Exam

    General:
    well developed, well nourished, in no acute distress.
    Head:
    normocephalic and atraumatic.
    Eyes:
    PERRL/EOM intact, conjunctiva and sclera clear with out nystagmus.
    Lungs:
    Wheezes with forced exhalation--has some rhonchus and bilateral lower lobe crackles.
    Heart:
    non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
    Psych:
    alert and cooperative; normal mood and affect; normal attention span and concentration.


    Impression & Recommendations:

    Problem # 1: BRONCHITIS, ACUTE (ICD-466.0)
    Assessment: New
    This is likely acute bronchitis. CXR, EKG, CBC, BNPEP, Sputum culture. BMP. DuoNeb. Treat with Zpack, Prednisone burst, DuoNeb.
    Her updated medication list for this problem includes:
    Advair Diskus Aepb (Fluticasone-salmeterol aepb)
    Mucinex D Xr12h-tab (Pseudoephedrine-guaifenesin xr12h-tab)
    Duoneb 2.5-0.5 Mg/3ml Soln (Albuterol-ipratropium) ..... Qid prn
    Zithromax Z-pak 250 Mg Tabs (Azithromycin) ..... As directed


    Medications Added to Medication List This Visit:
    1) Advair Diskus Aepb (Fluticasone-salmeterol aepb)
    2) Allergy Relief Tabs (Diphenhydramine hcl tabs)
    3) Mucinex D Xr12h-tab (Pseudoephedrine-guaifenesin xr12h-tab)
    4) Duoneb 2.5-0.5 Mg/3ml Soln (Albuterol-ipratropium) .... Qid prn
    5) Prednisone 10 Mg Tabs (Prednisone) .... 6 po qd for 5 days
    6) Zithromax Z-pak 250 Mg Tabs (Azithromycin) .... As directed
    7) Nebulizer With Supplies .... Use with duoneb every 6 hrs if needed for cough/wheeze

    Other Orders:
    Basic Metabolic Panel (BMP)
    CBC with diff (CBCD)
    Bacterial Culture (BACCUL)
    X-Ray, Chest, PA & Lateral (CPT-71020)
    EKG (EKG)

    Prescriptions:
    NEBULIZER WITH SUPPLIES Use with DuoNeb every 6 hrs if needed for cough/wheeze

  2. #2
    Default
    I am getting the same result; 99203. Everything revolves around 1 dx. There is much written in HPI, but it only involves a few areas. CPT is justified.

  3. Default
    Quote Originally Posted by ithomas14 View Post
    I am getting the same result; 99203. Everything revolves around 1 dx. There is much written in HPI, but it only involves a few areas. CPT is justified.
    I agree.

  4. Default E/M level
    thank you!

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