We have a pt that came to our office for regular follow up of his cardio problems. During the visit, he requested a letter be written to support his driving a school bus (that’s his regular job and he needs an annual "clearance" to drive due to his heart problems).
Doctor did his usual check up and mentioned that a separate letter is written. We do not do DOT clearances. Its just a letter to support him driving his bus.
Our coder insisted that a Z02.04 examination for driving license MUST be used. The insurance denied our first claim. Patient was upset.
As office manager, i suggested to remove Z02.04. Notes as follows:
Patient X came for his follow up appointment for his heart diseases.
The patient had left knee surgery with Dr. Simpson in June 2017. He continues to drive a school bus. He gained 13 pounds of weight. He has no new complaints but does have some low back pain, hip pain, and knee pain. He said he has no driving records. He has good eyesight and good coordination. He is able to continue to drive a school bus. He wants to drive a school bus. He wants to work.
Past Medical History:
Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris (1991) (stable angina pectoris),Coronary angioplasty status (January 2005) (to mid RCA in Ohio),Elevated body mass index (BMI 32),Essential (primary) hypertension (controlled),Fatigue,Ischemic cardiomyopathy,Mixed hyperlipidemia,MR – Mitral regurgitation (mild, lvef of 50 to 55%),Normal stress test (April 2009) (by Dr. Joseph Fredi at Vanderbilt),Old myocardial infarction (1991) (status post PTCA in Oregon),Pure hypercholesterolemia,Tricuspid regurgitation (mild)
Procedures:
Left knee surgery (June 2017),PTCA – Percutaneous transluminal coronary angioplasty (1991),Stent placement (2005)
Presenting Medications:
Altace 5mg (qam)
aspirin 81mg (qd)
atenolol 50mg (1/2 tablet qd)
Co Q-10 100mg (qd)
Fish Oil 1,000mg (qd)
Lipitor 80mg (qd)
Viagra tablet 50 -100mg (prn)
Zetia 10mg (qd)
Allergies:
NKDA
Social History: Smoking Status: Former smoker. Age Started Smoking: 19. Age Quit Smoking: 47. Language: English.
Family History:
Heart disease (Mother – CABG x5, CABG x3 died at age of 76), Stroke (Father – died at age of 66)
Vital Signs:
Ht Wt BMI BP – Sys BP – Dia BP – Site BP – Position
71 in 231 lbs [+13] 32.22 110 mmHg 58 mmHg Left Arm Sitting
Resp Temp Pulse Pulse Site Exertion O2 Sat Head Circ Pain Severity
60 bpm Radial Resting
Review Of Systems:
Constitutional: Negative for fever. Negative for weight loss. Positive for weight gain of 13 lbs. Negative for fatigue.
HEENT: Negative for blurred vision. Negative for tinnitus.
Pulmonary: Negative for shortness of breath. Negative for wheesing.
Cardiovascular: Negative for chest pain. Negative for dyspnea on exertion. Negative for palpitations. Negative for paroxysmal noctural dyspnea. Negative for syncope. Negative for leg edema.
Gastrointestinal: Negative for nausea. Negative for vomiting. Negative for constipation. Negative for heartburn. Negative for diarrhea. Negative for abdominal pain.
Endocrine: Negative for polydipsia. Negative for heat/cold intolerance.
Genitourinary: Negative for dysuri. Negative for hematuria.
Musculoskeletal: Negative for myalgia. Positive for arthralgia.
Neurological: Negative for unusual headache. Negative for dizziness. Negative for neurological deficit.
Integumentary: Negative for unusual rash. Negative for ecchymosis.
Hematologic: Negative for bleeding. Negative for bruising.
Physical Exam:
Constitutional:
General: Alert & Oriented x 3, Appeared to be in no acute distress.
HEENTe: Pink palpebral conjunctiva, Anicteric sclera.
Neck: Supple, No significant jugular venous distension, Carotid pulse appeared normal, No carotid bruit was appreciated.
Lungs: Clear to auscultation
COR: S1, S2, Regular rate & rhythm, Faint systolic murmur was appreciated, No pericardial friction rub, No S3, No S4.
Abdomen: Positive bowel sounds, Soft, Non-tender.
Extremities: No edema, No cyanosis.
Assessments:
Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris (1991) (stable angina pectoris)
Coronary angioplasty status (January 2005) (to mid RCA in Ohio)
Pure hypercholesterolemia
Essential (primary) hypertension (controlled)
Ischemic cardiomyopathy
MR – Mitral regurgitation (mild, lvef of 50 to 55%)
Elevated body mass index (BMI 32)
Tricuspid regurgitation (mild)
Plan:
Comprehensive review of patient’s history, records, lab results, work up results and medications.
Moderate complexity medical decision making.
Labs done recently showed cholesterol with excellent control with cholesterol 126, LDL 63.
Blood pressure and heart rate are well-controlled.
Continue optimal medical therapy. He is on high dose Lipitor 80 mg a day and so far he is able to tolerate that.
Stopped Slo-Niacin.
Patient uses Viagra sparingly. I informed him in no uncertain terms that he must not mix Viagra with nitroglycerin.
Please see a separate letter written for him regarding continuation of his being a driver for school bus.
Low salt, low fat diet.
Exercise training.
Meds:
No Medication Changes
Health Promotion:
Dietary Consult BMI outside of range
Follow-Up:
Follow up 6 months
I am rebilling it without the Z02.04 but needs validation. Just in case insurance comes back with question.
Thanks.
