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need E/M help

  1. #1
    Default need E/M help
    Medical Coding Books
    Is this a PE or problem visit?

    ALLERGIES:
    Onset Description Reaction
    05/10/2000 No Known Allergies

    PROBLEM:
    CHIEF COMPLAINT:
    wellness exam

    SUBJECTIVE:
    Patient presents with wellness exam.
    Comments: Eats a lot of fast food. Records show weight gain of > 40 lb since 2005. Brings bp diary; see scanned diary. Mult readings borderline or high.


    Chronic Conditions:

    none

    REVIEW OF SYSTEMS:

    Health Maintenance:
    Last tetanus on 10/31/2005.
    Last Eye Exam done on 04/24/2008.
    Last Pap Smear done on 06/15/2010.
    Health Maintenance Comments: had abnormal pap, had repeat at oschner, need update.

    has reviewed and updated the past medical, social and family history.

    OBJECTIVE:
    Vital Signs:
    Temperature: 98.20 by: oral Weight: 173.80 lbs Height: 63.00 in Head Circumference:
    Pulse: 89/min
    Respiration: 18/min
    Blood Pressure: Position Location Cuff
    120/ 90 sitting left arm regular Pain Rating Scale:
    Pain rated as 0 by : patient
    Patients BMI is 30.86 .

    Physical Exam:
    General:
    The patient is in no apparent distress.
    The patient is moderately obese.

    HEENT:
    Head:
    Neck:
    The neck is supple without thyromegaly, JVD, lymphadenopathy or carotid bruits.
    Ears:
    The ear canals are clear. The tympanic membranes are intact bilaterally.
    Mouth & Throat:
    The oropharynx is benign.

    Lungs:
    The chest is clear to auscultation and percussion. The breath sounds are equal bilaterally.

    Heart:
    The heart reveals a regular rate and rhythm with a normal S1 and S2. There are no murmurs or gallops appreciated.

    ASSESSMENT:
    Code Diagnosis
    796.2 ELEV BL PRES W/O HYPERTN
    V70.0 ROUTINE MEDICAL EXAM
    783.1 ABNORMAL WEIGHT GAIN



    PLAN:
    MEDICATION:
    Brand Generic Name Dose Sig Desc
    Z-pack Azithromycin Take as directed
    Sprintec Norgestimate-ethinyl Estradiol 0.25-0.035
    The medications have been reviewed by:.

    The following panel (s) were ordered:
    Panels
    General Health Panel
    Lipid Total [Care Panel #2]
    Lab Tech Comments: q/db
    Urinalysis
    Urine Auto w/o Microscope




    Plan notes: Wellness exam. Given and discussed info on htn, aerobic exercise and DASH diet. Begin exercise at least 1/2 hr per day. Discussed gardasil vaccine; requested copy of shot records. She will discuss gardasil with her gynecologist. Bring bp diary on f/u.
    Follow up: 3month(s)
    Follow up: PRN


    Patient Education:
    General Education Discussed:
    Diet specifics discussed with patient/responsible party. Exercise program discussed with patient/ responsible party. Monitoring outpatient BPs discussed with patient/responsible party.
    Patient urged to lose weight/continue efforts.

  2. #2
    Location
    Columbia, MO
    Posts
    12,962
    Default
    This is definitely a PE the V70.0 must be first listed you can include the other 2 dx codes but it will not change the CPT assignment of preventive level.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default
    Thanks Debra...

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