Has anyone ever seen this code?
My PA recently completed a note (copied below) and this code (DQ514P) popped up. Just wondering if anyone has ever seen this. I don't think I can bill for it, I don't even recognize it as a CPT or HCPCS code...but just thought I would check first....
Electronically signed by provider on 08/12/2008 10:34:33 AM
CC: She is here to follow-up birth control. She was not able to follow-up earlier because of interruption of insurance coverage.
Patient presents today with complaints of dizziness, nausea, and mood swings. She believes all these symptoms are related to using Yaz OCP. She says the symptoms started about 2 months after she started using the pills. She denies missing any doses and says she takes them religiously every evening at 9:00 pm. Her last period was 7/21/08. She says that the abdominal pain is improved and the pill has helped with those symptoms. She and her mother believe she is getting too much estrogen. She is now sexually active and states that she always uses condoms. She denies use of tobacco or illicit drugs. She has no other complaints.
CONSTITUTIONAL: Negative for chills, fatigue, fever, night sweats and victimization by domestic violence.
EYES: Negative for blurred vision, eye drainage, eye pain and photophobia.
E/N/T: Negative for hoarseness and sore throat.
CARDIOVASCULAR: Negative for chest pain, dizziness, paroxysmal nocturnal dyspnea, pedal edema and tachycardia.
RESPIRATORY: Negative for recent cough, chronic cough and frequent wheezing.
GASTROINTESTINAL: Positive for nausea. Negative for abdominal pain, acid reflux symptoms, anorexia, abdominal bloating, constipation, diarrhea or vomiting.
GENITOURINARY: Negative for genital lesions, hematuria, menstrual problems, polyuria, abnormal vaginal bleeding, and vaginal discharge.
MUSCULOSKELETAL: Negative for arthralgias, back pain, joint stiffness and myalgias.
NEUROLOGICAL: Negative for dizziness, fainting and headaches.
HEMATOLOGIC/LYMPHATIC: Negative for easy bruising, excessive bleeding and lymphadenopathy.
ENDOCRINE: Negative for hot flashes, polydipsia and excessive sweating.
ALLERGIC/IMMUNOLOGIC: Negative for risk factors for HIV.
PSYCHIATRIC: Positive for mood swings ( (since using the birth control pills) ).
Past Medical History / Family History / Social History:
Past Medical History:
Positive for Type 2 Diabetes ( mother; mat. GM ).
No Known Drug Allergies.
Yaz 0.02mg/3mg Tablet Take 1 tablet(s) by mouth daily as directed.
Symbicort 80mcg/4.5mcg Oral Inhaler Inhale 2 inhalation(s) by mouth bid
Current: 8/12/2008 9:46:43 AM
Wt: 124 lbs (43.02%)
T: 97.9 F (oral); BP: 112/72 mm Hg (left leg, sitting); P: 79 bpm (left arm (BP Cuff), sitting); R: 20 bpm
GENERAL: well developed, well nourished; well groomed; no apparent distress;
NECK: range of motion is normal; trachea is midline; thyroid is non-palpable; Supple
RESPIRATORY: normal appearance and symmetric expansion of chest wall; normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs;
CARDIOVASCULAR: normal rate; rhythm is regular; normal S1; normal S2;
NEUROLOGIC: mental status: alert and oriented x 3; cranial nerves II-XII grossly intact;
PSYCHIATRIC: appropriate affect and demeanor; normal thought and perception;
625.3 Dysmenorrhea - improved
Dysmenorrhea - improved
Mircette Biphasic Tablet Take 1 tablet(s) by mouth daily as directed. #1 (One) 28 tablet package Refills: 0
LABORATORY: Lab studies ordered today include CBC, TSH, and CMP.
FOLLOW-UP: Schedule a follow-up appointment in 2 weeks. For pap smear
Smoking Status: Nonsmoker Consider interaction of Symbicort with OCP that may be responsible for symptoms.
Automated complete blood count with platelets and complete differential
Thyroid stimulating hormone (TSH) CMP
Queried Patient for Tobacco Use
Schedule a follow-up visit in 2 weeks.
625.3 Dysmenorrhea - improved
99214 Office/outpatient visit; established patient, level 4
DQ514P Queried Patient for Tobacco Use
Kristie Stokes, CPC, AIHC ICDCT-CM
AAPCCA Board of Directors 2014-2017
Region 1 - Northeast
Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York
Today, give a stranger one of your smiles. It might be the only sunshine they see all day.