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Level for presciption refill?

  1. Default Level for presciption refill?
    Medical Coding Books
    Hi All,
    What is the appropriate Level of Service for a RX. Refill? because I have a provider who bill it as 99213 with notes as follows:
    54 yo male presents here for pain meds refills for arthritic low back pain. Reports doing fine with new meds including metformin and crestor, but havine 2 days of dark stools after starting on metformin and then normal stools--he refuses DRE for guaiac testing--states he has appointment with GI.
    Cardiovascular Negative for:, chest pain, palpitations, edema. General Negative for:, fever, chills, fatigue, loss of appetite, weight change. Respiratory Negative for:, cough, shortness of breath, breathing problems.

    General Examination
    GENERAL APPEARANCE: well nourished and hydrated, NAD, comfortable, alert, walks with a cane. EXTREMITIES: no clubbing, no edema, no cyanosis.

    Continue Baby Aspirin Tablet Chewable, 81 MG, Orally, 1 tablet, Once a day
    Continue Amlodipine Besylate Tablet, 5 MG, Orally, 1 tablet, Once a day
    Continue Metoprolol Succinate Tablet Extended Release 24 Hour, 100 mg, Orally, 1 tablet, Once a day
    BP is under good control.
    Continue Oxycodone-Acetaminophen Tablet, 10-325 MG, Orally, 60, 1 tablet as needed, twice a day, 30 days, Refills 0
    Reviewed pain contract
    Diabetes mellitus type 2
    Continue Metformin HCl Tablet, 850 MG, Orally, 1 tablet with a meal, Once a day
    HgbA1C from 7/20/11 was 6.5% and, he has gained weight even with less meals--pt agreed to trial Metformin with risk/benefits discussed.
    Continue Pancrelipase, as directed, twice a day with meals
    Continue Simethicone Tablet Chewable, 125 MG, Orally, 1 tablet as needed, Four times a day after meals and at bedtime
    Continue Ranitidine HCl Tablet, 150 MG, Orally, 1 tablet, Twice a day
    Continue Colace Capsule, 100 mg, Orally, 1 capsule as needed, Four times a day
    Hyperlipidemia NOS
    Continue Crestor Tablet, 10 mg, Orally, 1 tablet, Once a day
    pt agreed to trial statin with risk/benefits discussed--f/u in 4 weeks for LFT--informed pt of significant side effects/warnings with statin use
    Tobacco use disorder
    Continue Nicotine Polacrilex Gum, 4 MG, Mouth/Throat, 1 piece for 30 minutes as needed, 24 time(s) a day
    smoking 1PPD since age 23--now smokes 10 cigarettes/day
    Chronic pancreatitis NOS
    s/p multiple (> 4 times) admissions for acute exacerbation of chronic alcoholic pancreatitis after binge drinking-- pt advised against alcohol consumption to prevent flare-ups
    Portal vein thrombosis
    He had been f/u with anticoag clinic until 2 months ago, did sonogram/CT/MRI of liver, and was told his liver infarction has resolved--Dr. Adler took him off anticoagulants (he was on Lovenox, f/b coumadin, then Aristra injections)--medical records requested for this medical condition--will see GI in 4 weeks
    Continue Ambien Tablet, 10 mg, Orally, 30, 1 tablet at bedtime, Once a day, 30 days, Refills 0

    Diagnostic Imaging:
    Lab Reports:
    Preventive Medicine:
    Next Appointment:
    4 Weeks (f/u, fasting labs)

    Pls.needs any INPUT.

    Last edited by veloso; 10-26-2011 at 10:14 AM.

  2. #2
    Concord, NC or Rochester, NY
    the note meets the qualifications of a 99213. The bigger question which will become a major one soon is the medical necessity of the visit. Because of the basic information but the severity of all the scripts the patient has, if I was a provider the argument would be: see the patient to ensure there is not an issue or contraindication between drugs, etc.

    Therefore I would push to bill this as the provider wants

  3. Default
    Thanks a lot,Contributor...

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