KristieStokesCPC
Expert
I am trying to verify that the code our EMR system kicked out is legit. I actually think it should be coded a level 4 established, but I wanted to get feedback from my coding community:
Patient X 09/19/1920
Office/Outpatient Visit
Visit Date: Mon, Mar 2, 2009 11:43 am
Provider: Physician B (Supervisor: Physician A; assistant: Nurse A)
Location: Cantonment Family Medicine PA
Electronically signed by provider on 03/02/2009 02:41:20 PM
SUBJECTIVE:
CC:
Mr. patient is a 88-year-old male. He presents with upper back pain. worse with coughing when coughing
HPI:
Mr. patient c/o thoracic back pain for about a week, with worsening pain over weekend. No injury or fall. Pain is improved with alleve and lortab. Worsened by coughing.
Patient complains of upper back pain. The location is primarily in the mid thoracic spine. It does not radiate. He characterizes it as constant, severe, and sharp. He states that the current episode of pain started one week ago. He notes some pain relief with rest, NSAIDs, and narcotic pain medication. The pain worsens with coughing, moving.
Also c/o worsening B/L LE edema not controlled w/ his usual dose of lasix 40mg BID.
ROS:
CONSTITUTIONAL: Positive for fatigue. Negative for chills, fever, unintentional weight gain or unintentional weight loss.
EYES: Negative for blurred vision.
E/N/T: Negative for ear pain, diminished hearing, tinnitus, frequent epistaxis, frequent rhinorrhea, periodontal disease, hoarseness and sore throat.
CARDIOVASCULAR: Positive for pedal edema. Negative for chest pain, claudication, dizziness, orthopnea, palpitations, tachycardia or varicosities.
RESPIRATORY: Positive for chronic cough, dyspnea and frequent wheezing. Negative for recent cough, exposure to tuberculosis, hemoptysis or pleuritic chest pain.
GASTROINTESTINAL: Negative for abdominal pain, acid reflux symptoms, anorexia, abdominal bloating, dysphagia, constipation, diarrhea, heartburn, hematemesis, hematochezia, hemorrhoids, melena, nausea and vomiting.
MUSCULOSKELETAL: See HPI
NEUROLOGICAL: Negative for ataxia, dizziness, fainting, headaches, paresthesias, tremor and weakness.
HEMATOLOGIC/LYMPHATIC: Negative for easy bruising and excessive bleeding.
PSYCHIATRIC: Negative for anxiety, crying spells, depression, feelings of stress, anhedonia, personality change, difficulty concentrating, recreational drug use, sadness, sleep disturbance and suicidal thoughts.
Current Problems:
Cardiac angina
CHF
Chronic renal insufficiency
Congestive heart failure, unspecified
COPD
COPD
Coronary artery disease, of native coronary artery
Fatigue
Fatigue
GERD
Glucocorticoid deficiency
Late effect of superficial skin injury
Late effects of accidental fall
Osteoarthritis involving several sites
Peripheral vascular disease
Pernicious anemia
Type I diabetes, uncontrolled
Allergies:
No Known Drug Allergies.
Current Medications:
Humalog 100units/1ml Injection Inject as directed
Doxazosin Mesylate 1mg Tablet Take 1 tablet(s) by mouth daily
NitroQuick 0.4mg Tablets, Sublingual Dissolve 1 tablet(s) under the tongue may repeat every 5 minutes. Maximum of 3 doses in 15 minutes
Lisinopril 2.5mg Tablet Take 1 tablet(s) by mouth daily
Glipizide 10mg Tablets Take 1 tablet(s) by mouth qam before breakfast.
Furosemide 40mg Tablets Take 1 tablet(s) by mouth bid
Hydrocodone/Acetaminophen 7.5mg/500mg Tablet Take one tab po qid
Amitriptyline HCl 25mg Tablet 2 po qhs
Lantus 100units/1ml Injection 30 units are qhs
Metoprolol 25mg Tablet take one tablet bid
Prednisone 5mg Tablet Take 1 tablet(s) by mouth bid
Ferrous Sulfate 324mg Tablets one tablet bid
Metoclopramide HCl 10mg Tablet one tablet tid
fish oil one tablet three times a day
Combivent Oral Inhaler one puff bid
Omeprazole 20mg Capsules, Extended Release one tablet bid
OBJECTIVE:
Vitals:
Current: 3/2/2009 11:44:15 AM
Ht: 68 inches; Wt: 234 lbs; BMI: 35.58
T: 98.8 F (oral); BP: 112/55 mm Hg (left arm, sitting); P: 72 bpm (left arm (BP Cuff), sitting); R: 20 bpm
Exams:
PHYSICAL EXAM:
GENERAL: well developed, well nourished, moderately obese; well groomed; wife present.
E/N/T: EARS: external auditory canal normal; bilateral TMs are normal; OROPHARYNX: oral mucosa is normal; normal palate; normal tongue; posterior pharynx, including tonsils, tongue, and uvula are normal;
RESPIRATORY: normal respiratory rate and pattern with no distress; no rhonchi; no wheezes;
CARDIOVASCULAR: normal rate; rhythm is regular; normal S1; normal S2; no cyanosis; 2+ pedal edema;
MUSCULOSKELETAL: gait: slowed, unsteady, and ambulates with cane.; both sides of thoracic back w/ +TTP, no palpable step-off, no palpable crepitus. ROM exam limited by patients' overall difficulty with moving, difficulty ambulating.;
NEUROLOGIC: mental status: alert; cranial nerves II-XII grossly intact;
PSYCHIATRIC: appropriate affect and demeanor;
ASSESSMENT:
724.1 Upper back pain
782.3 Pedal edema patient currently on Lasix 40mg BID----states he feels better when he doubles up on morning dose----requests new prescription to reflect this.
ORDERS:
Meds Prescribed:
Refill of: Furosemide 40mg Tablets take 2 pills PO QAM and 1 pill PO QHS #90 (Ninety) tablet(s) Refills: 6
Naprosyn 500mg Tablet Take 1 tablet(s) by mouth bid #20 (Twenty) tablet(s) Refills: 1
PLAN:
Upper back pain
RADIOLOGY: I have ordered thoracic spine xray to be done today. will call patient with results.
Prescriptions:
Naprosyn 500mg Tablet Take 1 tablet(s) by mouth bid #20 (Twenty) tablet(s) Refills: 1
Pedal edema
Prescriptions:
Refill of: Furosemide 40mg Tablets take 2 pills PO QAM and 1 pill PO QHS #90 (Ninety) tablet(s) Refills: 6
CHARGE CAPTURE:
Primary Diagnosis:
724.1 Upper back pain
Orders:
99213 Office/outpatient visit; established patient, level 3
782.3 Pedal edema
ADDENDUMS:
____________________________________
Addendum: 03/03/2009 06:33 AM - Physician A
Reviewed and agreed. However, it may be a compression fracture, he is chronically on steroids for adrenal insufficiency and has multiple high risk medical problems.
Physician A
Thank you
Patient X 09/19/1920
Office/Outpatient Visit
Visit Date: Mon, Mar 2, 2009 11:43 am
Provider: Physician B (Supervisor: Physician A; assistant: Nurse A)
Location: Cantonment Family Medicine PA
Electronically signed by provider on 03/02/2009 02:41:20 PM
SUBJECTIVE:
CC:
Mr. patient is a 88-year-old male. He presents with upper back pain. worse with coughing when coughing
HPI:
Mr. patient c/o thoracic back pain for about a week, with worsening pain over weekend. No injury or fall. Pain is improved with alleve and lortab. Worsened by coughing.
Patient complains of upper back pain. The location is primarily in the mid thoracic spine. It does not radiate. He characterizes it as constant, severe, and sharp. He states that the current episode of pain started one week ago. He notes some pain relief with rest, NSAIDs, and narcotic pain medication. The pain worsens with coughing, moving.
Also c/o worsening B/L LE edema not controlled w/ his usual dose of lasix 40mg BID.
ROS:
CONSTITUTIONAL: Positive for fatigue. Negative for chills, fever, unintentional weight gain or unintentional weight loss.
EYES: Negative for blurred vision.
E/N/T: Negative for ear pain, diminished hearing, tinnitus, frequent epistaxis, frequent rhinorrhea, periodontal disease, hoarseness and sore throat.
CARDIOVASCULAR: Positive for pedal edema. Negative for chest pain, claudication, dizziness, orthopnea, palpitations, tachycardia or varicosities.
RESPIRATORY: Positive for chronic cough, dyspnea and frequent wheezing. Negative for recent cough, exposure to tuberculosis, hemoptysis or pleuritic chest pain.
GASTROINTESTINAL: Negative for abdominal pain, acid reflux symptoms, anorexia, abdominal bloating, dysphagia, constipation, diarrhea, heartburn, hematemesis, hematochezia, hemorrhoids, melena, nausea and vomiting.
MUSCULOSKELETAL: See HPI
NEUROLOGICAL: Negative for ataxia, dizziness, fainting, headaches, paresthesias, tremor and weakness.
HEMATOLOGIC/LYMPHATIC: Negative for easy bruising and excessive bleeding.
PSYCHIATRIC: Negative for anxiety, crying spells, depression, feelings of stress, anhedonia, personality change, difficulty concentrating, recreational drug use, sadness, sleep disturbance and suicidal thoughts.
Current Problems:
Cardiac angina
CHF
Chronic renal insufficiency
Congestive heart failure, unspecified
COPD
COPD
Coronary artery disease, of native coronary artery
Fatigue
Fatigue
GERD
Glucocorticoid deficiency
Late effect of superficial skin injury
Late effects of accidental fall
Osteoarthritis involving several sites
Peripheral vascular disease
Pernicious anemia
Type I diabetes, uncontrolled
Allergies:
No Known Drug Allergies.
Current Medications:
Humalog 100units/1ml Injection Inject as directed
Doxazosin Mesylate 1mg Tablet Take 1 tablet(s) by mouth daily
NitroQuick 0.4mg Tablets, Sublingual Dissolve 1 tablet(s) under the tongue may repeat every 5 minutes. Maximum of 3 doses in 15 minutes
Lisinopril 2.5mg Tablet Take 1 tablet(s) by mouth daily
Glipizide 10mg Tablets Take 1 tablet(s) by mouth qam before breakfast.
Furosemide 40mg Tablets Take 1 tablet(s) by mouth bid
Hydrocodone/Acetaminophen 7.5mg/500mg Tablet Take one tab po qid
Amitriptyline HCl 25mg Tablet 2 po qhs
Lantus 100units/1ml Injection 30 units are qhs
Metoprolol 25mg Tablet take one tablet bid
Prednisone 5mg Tablet Take 1 tablet(s) by mouth bid
Ferrous Sulfate 324mg Tablets one tablet bid
Metoclopramide HCl 10mg Tablet one tablet tid
fish oil one tablet three times a day
Combivent Oral Inhaler one puff bid
Omeprazole 20mg Capsules, Extended Release one tablet bid
OBJECTIVE:
Vitals:
Current: 3/2/2009 11:44:15 AM
Ht: 68 inches; Wt: 234 lbs; BMI: 35.58
T: 98.8 F (oral); BP: 112/55 mm Hg (left arm, sitting); P: 72 bpm (left arm (BP Cuff), sitting); R: 20 bpm
Exams:
PHYSICAL EXAM:
GENERAL: well developed, well nourished, moderately obese; well groomed; wife present.
E/N/T: EARS: external auditory canal normal; bilateral TMs are normal; OROPHARYNX: oral mucosa is normal; normal palate; normal tongue; posterior pharynx, including tonsils, tongue, and uvula are normal;
RESPIRATORY: normal respiratory rate and pattern with no distress; no rhonchi; no wheezes;
CARDIOVASCULAR: normal rate; rhythm is regular; normal S1; normal S2; no cyanosis; 2+ pedal edema;
MUSCULOSKELETAL: gait: slowed, unsteady, and ambulates with cane.; both sides of thoracic back w/ +TTP, no palpable step-off, no palpable crepitus. ROM exam limited by patients' overall difficulty with moving, difficulty ambulating.;
NEUROLOGIC: mental status: alert; cranial nerves II-XII grossly intact;
PSYCHIATRIC: appropriate affect and demeanor;
ASSESSMENT:
724.1 Upper back pain
782.3 Pedal edema patient currently on Lasix 40mg BID----states he feels better when he doubles up on morning dose----requests new prescription to reflect this.
ORDERS:
Meds Prescribed:
Refill of: Furosemide 40mg Tablets take 2 pills PO QAM and 1 pill PO QHS #90 (Ninety) tablet(s) Refills: 6
Naprosyn 500mg Tablet Take 1 tablet(s) by mouth bid #20 (Twenty) tablet(s) Refills: 1
PLAN:
Upper back pain
RADIOLOGY: I have ordered thoracic spine xray to be done today. will call patient with results.
Prescriptions:
Naprosyn 500mg Tablet Take 1 tablet(s) by mouth bid #20 (Twenty) tablet(s) Refills: 1
Pedal edema
Prescriptions:
Refill of: Furosemide 40mg Tablets take 2 pills PO QAM and 1 pill PO QHS #90 (Ninety) tablet(s) Refills: 6
CHARGE CAPTURE:
Primary Diagnosis:
724.1 Upper back pain
Orders:
99213 Office/outpatient visit; established patient, level 3
782.3 Pedal edema
ADDENDUMS:
____________________________________
Addendum: 03/03/2009 06:33 AM - Physician A
Reviewed and agreed. However, it may be a compression fracture, he is chronically on steroids for adrenal insufficiency and has multiple high risk medical problems.
Physician A
Thank you