I am new to E&M coding and need help coding the below note. I calculated 99214 with DX codes N40.0, K21.9, I10, E03.9, Z86.79, Z95.5. Any input would be greatly appreciated.

REASON FOR VISIT: Follow up of primary care.

HISTORY OF PRESENT ILLNESS: The patient is a 69 yrs. old, last seen 5/18, who states he’s been doing well except that he is having worsening BPH symptoms. Last w/up IU 5?17. He was told there was nothing they could offer. Pt also is having a lump in his throat when he swallows, but not when he eats or drinks. No abd pain, change in stools, fatigue, and only an intentional weight loss. There have been no hospital admissions or ER visits since the last clinic visit. No other health concerns. Med list reviewed and refills given.

PAST MEDICAL HISTORY: Compensated hypothyroidism, Low back pain, Coronary arteriosclerosis in native artery, Dream anxiety disorder, Hyperlipidemia, Benign essential hypertension, Iron defed anemia, Hearing loss, GERD, Hemorrhoids, Colonic polyps, SCC of rt hand

REVIEW OF SYSTEMS: General: No fever, chills, or anorexia, dec intentionally 10 lbs. NECK: no swelling, stiffness, pain CHEST: No dyspnea, pleuritic CP, or URI symptoms COR: No CP, SOB, Diaphoresis, PND, or edema ABD: No abd pain, N/V, change in stools or blood GU: Worsening symptoms, nocturia, not assc with diet, or fluids PSYCHE: No SI/HI, sleeping well, appropriate affect

PHYSICAL EXAMINATION: Gen: WD, WN, BMI 28 dec 10 lbs, W, in NAD, VSS, Afebrile Chest: Bilateral clear CVS: S1 S2 present, No murmur ABD: Soft, Non tender, Bowel sound present, No organomegaly EXT: No LE edema CNS: C, A, Ox3, No focal deficit.

LABORATORY: Reviewed and discussed

ASSESSMENT/PLAN: #Hypertension – controlled cont same #Hx of CAD s/p stents=stable #Hypothy- WNL cont same SYN .1 #BPH- Worsening despite max meds, last URO consult 7/17. #Constipation- batter with corrected Thy #GERD- Not much better, despite meds. Will make sure taking correctly, if he is will get GI consult.