Provider wanting to bill Annual Pe and 99214. Patient has Sterling. I feel that we should bill the G0439 due to her coming in for annual pe. No pap was done. Please see document below any advice would be great!

Primary Provider:
CC: Annual PE.

History of Present Illness:
In for yearly exam. She has decreased her plaquenil to once daily due to some concerns from the opthalmologist regarding possible toxicity. She has noticed some increased achiness on the lower dose. She has stopped the ibuprofen due to stomach upset.

She reports pain in her right side that radiates into her leg off and on. Worse in the mornings and at times makes it difficult to walk. She has a hard time pin-pointing the area of pain- points to outside of her hip, but also to her lower ribs and her right buttock.

Blood pressures have been under good control- occasionally running as low as 95/63. She wonders if she can go off some of her medication. Needs refill on micardis.

She has h/o osteoporosis of the spine and has undergone one reclast infusion which she tolerated ok. Is wondering if she needs to have another one. Last bone density test was over 2 years ago.

She is up to date on colonoscopy. She is due for mammogram. Had pap last year that was normal and has never had abnormal. She had fasting labwork done this summer that showed normal lipids; GFR reduced slightly.

Past Medical History:
Reviewed history from 06/21/2010 and no changes required:
Patient indicates medical history of hypertension, osteopenia. Other medical history includes: osteoarthritis, sjogren's disease, rosacea

Past Surgical History:
Patient reports surgical history to include: tonsillectomy, tubal ligation, varicose vein surgery. cataract surgery; colonoscopy 2010

Family History:
Reviewed history from 06/21/2010 and no changes required:
Father is deceased. He died of disease. Mother is deceased. The patient indicates family history of colon cancer (mother), prostate cancer (father, brother), stroke (brother), coronary artery disease (brother), osteoporosis (mother), arthritis (brother). brother- leukemia

Social History:
Reviewed history from 12/28/2006 and no changes required:
She lives with her spouse. She is Married.

Risk Factors:

Tobacco use: never
Passive smoke exposure: no
HIV high-risk behavior: no
Caffeine use: Drinks coffee, tea times per day.
Alcohol use: yes
Type: Drinks wine, liquor 1 time per month having 1-2 per occasion. Never has more than five drinks per occasion.
Exercise: yes
Times per week: 3-4 /wk
Type: walking, aerobics
Seatbelt use: 100 %

Family History Risk Factors:
Family History of MI in females < 65 years old: no
Family History of MI in males < 55 years old: no

Review of Systems

Denies fever.

Denies nasal congestion and sore throat.

Denies chest pain or discomfort, racing/skipping heart beats, and swelling of hands or feet.

Denies cough and shortness of breath.

Denies nausea, vomiting, abdominal pain, diarrhea, and constipation.

Denies painful urination.

Complains of joint pain.

Denies suspicious lesions and rash.

Denies numbness and weakness.

Vital Signs:

Patient Profile: 76 Years Old Female
Height: 61.5 inches
Weight: 148.5 pounds
BMI: 27.70
BSA: 1.68
Temp: 96.0 degrees F tympanic
Pulse rate: 68 / minute
Pulse rhythm: regular
BP sitting: 122 / 78 (left arm)
Cuff size: regular

Vitals Entered By:

Physical Exam

well developed, well nourished, in no acute distress.
no masses, thyromegaly, or abnormal cervical nodes. no bruit.
no masses, adenopathy or nipple discharge.
clear bilaterally to auscultation.
regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
normal bowel sounds; no hepatosplenomegaly no ventral,umbilical hernias or masses noted.
normal female external genitalia. uterus small, anterior; adnexa not palpable on bimanual exam
I can elicit no bony tenderness of iliac crest or ribs on palpation; there is some tenderness of the right greater trochanter of the hip; there is some tenderness of the right SI joint
pedal pulses full
no edema
occasional seborrheic keratoses; no worrisome lesions
Cervical Nodes:
no significant adenopathy.
Axillary Nodes:
no significant adenopathy.
alert and cooperative; normal mood and affect; normal attention span and concentration.

Impression & Recommendations:

Problem # 1: WELL ADULT EXAM (ICD-V70.0)
pap deferred; mammogram order given; up to date on colonoscopy

Problem # 2: OSTEOPENIA (ICD-733.90)

Her updated medication list for this problem includes:
Calcium Citrate Tabs (Calcium citrate tabs) ..... 1 tab po qd
Vitamin D3 2000 Unit Caps (Cholecalciferol) ..... 1 tab po qd

will get bone density test done; probably does not need reclast


Problem # 3: HYPERTENSION (ICD-401.9)

Her updated medication list for this problem includes:
Amlodipine Besylate 5 Mg Tabs (Amlodipine besylate) ..... 1/2 po daily
Micardis Hct 80-12.5 Mg Tabs (Telmisartan-hctz) ..... 1 tab po once daily

she will decrease amlodipine to 2.5mg daily for one month and if BP's stay within goal range, she can d/c that medication; if BPs start running over 135/85 shs should restart the med

she will stop the plaquenil and let me know in 4-6 weeks how she is doing with pain levels; call if the right sided hip pain becomes more pronounced or persistent

Medications Added to Medication List This Visit:
1) Amlodipine Besylate 5 Mg Tabs (Amlodipine besylate) .... 1/2 po daily
2) Omega 3 Cpdr (Omega-3 fatty acids cpdr) .... 1 tab po qd
3) Calcium Citrate Tabs (Calcium citrate tabs) .... 1 tab po qd
4) Vitamin D3 2000 Unit Caps (Cholecalciferol) .... 1 tab po qd
5) Century Mature Tabs (Multiple vitamins-minerals) .... 1 tab po qd

Other Orders:
Mammogram, Bilateral Screening (CPT-76091)

MICARDIS HCT 80-12.5 MG TABS (TELMISARTAN-HCTZ) 1 tab PO once daily #90 x 0