I always feel stressed when we have a new provider come on board with our facility and we have differences on E/Ms. In this case the provider coded this visit as 99214. I down coded it to a 99213 based on the following (follow up on one problem worsening or not responding to treatment, HPI, and time spent with patient). I do thing the MDM is Moderate but I am not sure that trumps everything else? I would appreciate your opinions!

75 year old female who is 1.5 weeks post-op from aortic valve replacement (TAVR), with history of peripheral neuropathy, multiple spinal surgeries, Addison’s disease, atrial fibrillation s/p AICD/pacemaker on warfarin, CAD here for left leg pain and increased swelling.
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Leg swelling.
– INR 1.3
-no lightheadedness/dizziness
– has had palpitations the last few days; had them most recently this am.
-feels like she is getting adequate air; no shortness of breath
-no chest pain
-left leg swelling from knee down worse than usual
-new pain in her calf that is different from her neuropathic pain.
-neuropathy in both feet, unable to tell whether there is pain or tingling
– no history of DVT or PE that she can recall.
– she does not believe that she was on heparin or lovenox in hospital. She is very worried about an allergic reaction if she were to start a new medication today.

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Dr. Siwek’s note says: "Coumadin was started for possible valve leaflet thrombosis. Did not improve gradient – hence TAVR. Probably not unreasonable to continue initially post TAVR but indication/duration a little unclear."
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Review of Systems
Constitutional: Negative for chills and fever.
Respiratory: Negative for cough, shortness of breath and wheezing.
Cardiovascular: Positive for palpitations and leg swelling (left leg). Negative for chest pain, orthopnea and PND.
Gastrointestinal: Positive for nausea. Negative for constipation, diarrhea and vomiting.
Genitourinary: Negative for dysuria and urgency.
Skin: Negative for rash.
Neurological: Negative for dizziness and headaches.
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Patient Active Problem List
Diagnosis
• Chronic adrenal insufficiency (HCC-CMS)
• GERD (gastroesophageal reflux disease)
• Vaginal prolapse
• Psoriasis
• Atrial fibrillation (HCC-CMS)
• Pacemaker
• Breast cancer screening
• Pernicious anemia
• Mitral valve insufficiency and aortic valve insufficiency
• Mixed hyperlipidemia
• Peripheral vascular disease, unspecified (HCC-CMS)
• Coronary artery disease with angina pectoris with documented spasm (HCC-CMS)
• Colon cancer screening
• Essential hypertension
• Controlled substance agreement signed, pending scanned documents
• Fusion of spine of thoracolumbar, multilevel fixation screws, hx revision fo broken hardware
• Other osteoporosis without current pathological fracture
• Chronic obstructive pulmonary disease (HCC)
• Proctitis
• Gout
• Allergic rhinitis
• Chronic pain of multiple sites
• Hypertrophic cardiomyopathy (HCC-CMS)
• Chronic pain of right knee
• Opioid dependence on agonist therapy (HCC-CMS)
• Pulmonary hypertension (HCC-CMS)
• Ulcer of great toe (HCC-CMS)
• Physician orders for life-sustaining treatment (POLST) form indicates patient wish for full code resuscitation status
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Past*Medical*History
Past Medical History:
Diagnosis Date
• Addison disease (HCC-CMS) *
• Asthma *
• Cataract *
• DJD (degenerative joint disease) *
• Fibromyalgia *
• GERD (gastroesophageal reflux disease) *
• HTN (hypertension) *
• Hypercholesterolemia *
• Mammary dysplasia *
• Pap smear 12-29-05
* normal
• Psoriasis *
• PUD (peptic ulcer disease) *
• PVD (peripheral vascular disease) (HCC-CMS) *
• Rhinitis, allergic *
• Tobacco use disorder *
• Vaginal prolapse *
• Valvular heart disease 8/29/2015
* 11/2012 s/p tissue mitral and aortic valve replacement b Dr Siwek. Severe MR with hypertrophic cardiomyopathy, mild aortic stenosis.

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Past*Surgical*History
Past Surgical History:
Procedure Laterality Date
• APPENDECTOMY; * *
• ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING, ARTICULAR CARTILAGE (CHONDROPLASTY) * *
* benign bone tumer removed
• COLONOSCOPY * 10-29-12
* Dr.Rose
• COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; DX, W/WO SPECIMENS/COLON DECOMP (SEP PROC) * 7/28/16
* Colonoscopy
• CORONARY ART/GRFT ANGIO S&I * 8/4/15
* Coronary cath/angio
• DOPPLER ECHOCARDIOGRAPHY; COMPLETE * 7/2016
* LVEF low normal, 50-55%. Pacer/defibrillator present, bioprosthetic MV present and appears to be functioning normally. Trace MR, mild TR. PA pressure 47mmHg. Bioprosthetic aortic valve appears to be functioning normally.
• EMBOLECTOMY/THROMBECTOMY; FEMOROPOPLITEAL/AORTOILIAC ARTERY, LEG INCISION * 6/30/15
* Left common & deep femoral artery thrombectomy, left iliofemoral embolectomy, patch angioplasty of left common & deep femoral artery placment of left external iliac artery, Left 6/30/15
• EXTREMITY STUDY * 8/4/15
* Left LE US negative for DVT
• FEM/POPL REVAS W/ATHER * *
• HEMIARTHROPLASTY, HIP, PARTIAL * *
* L total hip followed by reattachment of muscle following surgery
• LAMINECTOMY, W/O FACETECTOMY/FORAMINOTOMY/DISKECTOMY, 1/2 SEGMENTS; LUMBAR * *
* Laminectomy, Lumbar 13 back surgeries
• NEUROPLASTY &/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL * *
* bilateral carpal tunnel
• OOPHORECTOMY, PARTIAL/TOTAL, UNILAT/BILAT * *
* bilateral
• REPAIR ARTERIAL BLOCKAGE * 11/11/15
* SUCCESSFUL PTA OF L COMMON FEMORAL ARTERY WITH DRUG COATED BALLOON
• UNLISTED PROC, FOOT/TOES * *
* toe surgery by Dr. Clarke after shovel injured her toe.
• UNLISTED PROC, LEG/ANKLE * *
* "ankle surgery"
• UNLISTED PROC, SPINE * *
* thoracolumbar fixation hardware
• VAGINAL HYSTERECTOMY, UTERUS >250 GMS; * *

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Social*History
Social History
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Social History
• Marital status: Single
* * Spouse name: N/A
• Number of children: 5
• Years of education: 14
*

Occupational History
• Not on file.
*

Social History Main Topics
• Smoking status: Former Smoker
* * Quit date: 12/11/2008
• Smokeless tobacco: Never Used
• Alcohol use No
• Drug use: No
• Sexual activity: Not on file
*

Other Topics Concern
• Not on file
*

Social History Narrative
* Lives alone, her daughter lives a block from her

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Current Outpatient Prescriptions
Medication Sig Dispense Refill
• metoclopramide HCl (REGLAN) 10 mg tablet Take 1 Tab by mouth 4 (four) times daily before meals and nightly 120 Tab 3
• polymyxin B sulf-trimethoprim (POLYTRIM) 10,000 unit- 1 mg/mL ophthalmic solution Place 1 Drop into the right eye 4 (four) times daily 10 mL 0
• promethazine (PHENERGAN) 25 mg tablet TAKE 1 TABLET BY MOUTH EVERY 8 HOURS AS NEEDED FOR NAUSEA. 30 Tab 0
• promethazine (PHENERGAN) 25 mg tablet TAKE 1 TABLET BY MOUTH EVERY 8 (EIGHT) HOURS AS NEEDED FOR NAUSEA 30 Tab 5
• buprenorphine-naloxone (SUBOXONE) 8-2 mg SL tablet DISSOLVE 1/2 TABLET UNDER THE TONGUE 3 TIMES A DAY. 42 Tab 0
• predniSONE (DELTASONE) 5 mg tablet Take 2 Tabs by mouth once daily 90 Tab 3
• ondansetron HCl (ZOFRAN) 4 mg tablet TAKE 1 TABLET BY MOUTH EVERY 4 HOURS AS NEEDED FOR NAUSEA. 60 Tab 3
• allopurinol (ZYLOPRIM) 300 mg tablet Take 1 Tab by mouth once daily 30 Tab 5
• gabapentin (NEURONTIN) 600 mg tablet Take 1 Tab by mouth 2 (two) times daily 180 Tab 6
• ergocalciferol, vitamin D2, (VITAMIN D2) 50,000 unit capsule Take 1 Cap by mouth once a week 12 Cap 3
• PNV,calcium 72-iron-folic acid 27 mg iron- 1 mg tab Take 1 Tab by mouth once daily * *
• fluticasone (FLONASE) 50 mcg/actuation nasal spray Place 2 Sprays into the nostril(s) once daily 16 g 11
• carvedilol (COREG) 6.25 mg tablet Take 1 Tab by mouth 2 (two) times daily with a meal * *
• alirocumab 75 mg/mL pnij Inject 75 mg into the skin every 14 (fourteen) days. * *
• cyclobenzaprine (FLEXERIL) 10 mg tablet TAKE ONE TABLET BY MOUTH THREE TIMES DAILY AS NEEDED FOR MUSCLE SPASMS 30 Tab 5
• meclizine (BONINE) 25 mg tablet Take 25 mg by mouth 2 (two) times daily as needed. * *
• ENTERIC COATED ASPIRIN 81 MG TAB, DELAYED RELEASE 1T PO QD 30 Tab 11
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No current facility-administered medications for this visit.

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Objective

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Vitals
Vitals:
* 09/17/18 1000
BP: 134/65
Pulse: 79
Resp: 16
Temp: 97.8 °F (36.6 °C)
TempSrc: Oral
SpO2: 95%
Weight: 139 lb (63 kg)
Height: 5′ 1" (1.549 m)

Last 3 Vitals
Office Visit from 9/17/2018 in Winding Waters Medical Clinic Office Visit from 9/13/2018 in WW JOSEPH MEDICAL CLINIC Office Visit from 8/16/2018 in WW JOSEPH MEDICAL CLINIC
Temp 97.8 °F (36.6 °C) 97.8 °F (36.6 °C) 97.5 °F (36.4 °C)
Pulse 79 85 85
BP 134/65 106/56 115/73
Resp 16 16 20
Weight 139 lb (63 kg) 141 lb (64 kg) 139 lb (63 kg)
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Estimated body mass index is 26.26 kg/m² as calculated from the following:
Height as of this encounter: 5′ 1" (1.549 m).
Weight as of this encounter: 139 lb (63 kg).
Facility age limit for growth percentiles is 20 years.
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Physical Exam
Constitutional: She is oriented to person, place, and time. No distress.
Pale elderly female
HENT:
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Nose: Nose normal.
Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus.
Neck: Normal range of motion. Neck supple. No thyromegaly present.
Cardiovascular: Normal rate and regular rhythm.
No murmur heard.
2+ femoral pulses bilaterally. Unable to palpate DP or tibialis posterior pulses
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress.
Abdominal: Bowel sounds are normal. She exhibits no distension and no mass. There is no tenderness.
Musculoskeletal: She exhibits edema.
1+ pitting pedal edema bilaterally
Lymphadenopathy:
She has no cervical adenopathy.
Neurological: She is alert and oriented to person, place, and time. No cranial nerve deficit.
Skin: Skin is warm and dry. She is not diaphoretic. No pallor.
Psychiatric: She has a normal mood and affect. Her behavior is normal.
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Assessment and Plan: 75 year old female who is 1.5 weeks post-op from aortic valve replacement (TAVR), with history of multiple spinal surgeries, Addison’s disease, atrial fibrillation s/p AICD/pacemaker on warfarin, CAD here for left leg pain and increased swelling. Given recent surgery and subtherapeutic INR, there is concern for DVT/PE. However, patient’s leg swelling is relatively unimpressive with no erythema, warmth, collateral veins or significant enlargement compared to other side. I reviewed discharge summary and records from her recent hospitalization. Per her thoracic surgeon, unclear benefit of warfarin in this situation, and duration of therapy also unclear. No shortness of breath now and VS are within normal limits, making pulmonary embolism less likely, but she has had palpitations last 2 days. Other etiologies of palpitations could be cardiac arrhythmia such as rapid atrial fibrillation, dehydration, anxiety. None of these are apparent today.
– LLE duplex now.
– shared decision making around CTPA – patient declines at this time and I think this is reasonable – see above.
– will rx lovenox if US shows DVT.
– strict return precautions given – see instructions.
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R60.0 Edema of left lower extremity (primary encounter diagnosis)
Plan : • US STUDY FOLLOW-UP (SPECIFY) (Future)
• US STUDY FOLLOW-UP (SPECIFY)
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I48.91 Atrial fibrillation, unspecified type (HCC-CMS)
Plan : • INR COAGUCHEK (POCT)
INR 1.3 today. Plan to increase warfarin dosing to 10 mg on Monday and Friday and 5 mg the rest of the week. Recheck Friday 9/21/2018
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M79.605 Left leg pain
Likely explained by peripheral neuropathy. Continue gabapentin. Will monitor.
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Total of 20 minutes was spent with the patient. Greater than 50% of time was spent in FTF counseling and coordination of care for the above diagnoses.
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