Provider coding office note below 99215. Patient has multi problems but none seem to be life threatening. Patient was not sent to ED for evaluation or sent out to any other facility for evaluation. This provider uses the 99215 quite frequently. He will code a 99215 for a Established patient to himself or the group for a Screening Colonoscopy and he’s the provider that will be preforming the Colonoscopy. His usage of 99215 makes me very uncomfortable and all coders at this facility have sent him notes regarding his usage of the 99215. We code for a Family Medicine Clinic Group.
Primary Care Provider: DR A
Accompanied by: Spouse
Visit Type: Acute Visit
Chief Complaint: f/u ED -continued rectal bleeding and belching
History of Present Illness:
Patient is a Years Old _ who presents for severe pain s/p umbilical hernia repair 2 days ago. Last night he/she began to have severe abdominal pain. He/She started having blood in his/her stool and went to the ER last night. He/She was sent home. WBC slightly elvated at 13.6 and Creatinine slightly increased at 1.47. He/She has a decreased appetite but has been able to tolerate liquids and solids without vomit. He/She has some severe abdominal pain and nauseated. He/She noticed incfeased urinary frequency which is clear/yellow color.
ER records reviewed which had a normal rectal exam.
Mild constipation from being on hydrocdone.
Problem List Changes:
Added new problem of Body mass index (BMI) 38.0-38.9, adult (ICD-V85.38) (ICD10-Z68.38) – Signed
Added new problem of Hematochezia (ICD-578.1) (ICD10-K92.1) – Signed
Added new problem of Other acute postprocedural pain (ICD-338.18) (ICD10-G89.18) – Signed
Added new problem of Abdominal pain, acute (ICD-789.00) (ICD10-R10.9) – Signed
Removed problem of Abdominal pain, acute (ICD-789.00) (ICD10-R10.9) – Signed
Added new problem of Abdominal pain, acute (ICD-789.00) (ICD10-R10.9) – Signed
Added new problem of Acute nontraumatic kidney injury (ICD-584.9) (ICD10-N17.9)
Assessed Abdominal pain, acute as new – Signed
Assessed Other acute postprocedural pain as deteriorated – Signed
Assessed Hematochezia as unchanged – Signed
Assessed Acute nontraumatic kidney injury as new
Assessed Abdominal pain, acute as unchanged
Medication List: (Reviewed and Updated)
IBUPROFEN 800 MG ORAL TABLET (IBUPROFEN) 1 po tid
MONTELUKAST SOD 10 MG TAB 10 TAB (MONTELUKAST SODIUM) TAKE ONE TABLET BY MOUTH DAILY
ZYRTEC ALLERGY 10 MG ORAL TABLET (CETIRIZINE HCL) 1 po qd
AVAPRO 300 MG ORAL TABLET (IRBESARTAN) 1 po qd
NORVASC 5 MG ORAL TABLET (AMLODIPINE BESYLATE) 1-2 po qd
ALDACTONE 25 MG ORAL TABLET (SPIRONOLACTONE) 1 po qd
CHLORTHALIDONE 25 MG ORAL TABLET (CHLORTHALIDONE) 1 po qd
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR SOLUTION (TESTOSTERONE CYPIONATE) INJECT 2CC INTRAMUSCULARLY EVERY 2 WEEKS
YALE DISP NEEDLES 22G X 1-1/2" MISC (NEEDLE (DISP)) use as directed with Testosterone given IM q 2weeks
SYRINGE DISPOSABLE 3 ML (SYRINGE (DISPOSABLE)) use as directed with Testosterone IM q 2 weeks
BD DISP NEEDLES 18G X 1-1/2" (NEEDLE (DISP)) use as directed, use to draw up Testosterone give IM q 2weeks
Allergy List: (Reviewed and Updated)
No known allergies
Medical History: (Reviewed and Updated)
hypogonadism
traumatic brain injury
benign essential hypertension
onchmycosis
Sleep apnea
renal insuficency
allergic rhinitis
Surgical History: (Reviewed and Updated)
inguinal hernia
Nasla septum surgery
Social History: (Reviewed and Updated)
married with two children both boys.
Patient has never smoked.
Alcohol Use – yes
Drug Use – no
Regular Exercise – yes
Family History: (Reviewed and Updated)
aunt dementia
father type 2 diabetes
father hypertension
mother obese
Risk Factors:
Tobacco: (Reviewed and Updated)
Review of Systems:
COMPLAINS OF FEVER, CHILLS. All other systems reviewed and are negative
General: COMPLAINS OF FEVER, CHILLS.
Cardio: Denies chest pain, palpitations.
Respiratory: Denies SOB, cough.
GI: COMPLAINS OF ABDOMINAL PAIN, NAUSEA, CONSTIPATION, BLOOD IN STOOLS. Denies vomiting, diarrhea.
Vital Signs:
Weight: 274.2 lbs. (124.64 Kg.) Height: 71 in. (180.34 cm.) BMI: 38.38
Temperature: 97.6 deg F. (36.4 deg C.) Temperature Site: Temporal Pulse: 88 Pulse Rhythm: Regular
Blood Pressure #1: 138/88 mm Hg. Location: Rt Arm Position: sitting
Entered by:
Physical Exam:
General: Well developed, well groomed, in no acute distress.
Head: Normocephalic/atraumatic.
Eyes: PERRL, EOMI; conjunctiva and sclera clear.
Nose: No deformity/significant septal deviation; Normal mucosa.
Mouth: Mucus membranes moist; No erythema / exudates.
Neck: Supple; No thyromegaly or nodules.
Lungs: Clear to auscultation bilaterally.
Cardio: RRR; Normal S1, S2; Without murmurs, gallops, rub, or click.
Abdomen: severe periumbilical pain with guarding/ neg rebound
well healing periumbilical incision with some subcutaneous eccymosis
No masses
No hepatosplenomegaly
+BS
Extremity: No cyanosis or edema.
Skin: No rashes or atypical lesions.
Psych: Alert and oriented.
Assessment and Plan:
ABDOMINAL PAIN, ACUTE (ICD-789.00) (ICD10-R10.9) Unchanged
concern for hematochezia s/p abdominal surgery. intra-op report reviewed which showed no acute complication.
recommend stat CT abd/pelvis (just approved with insurance). sent to radiology for labs and CT scan
OTHER ACUTE POSTPROCEDURAL PAIN (ICD-338.18) (ICD10-G89.18) Deteriorated
pain worse than expected.
HEMATOCHEZIA (ICD-578.1) (ICD10-K92.1) Unchanged
blood in stool is concerning.
pt had colonoscopy 2016 unremarkable except for a small sessile polyp
ACUTE NONTRAUMATIC KIDNEY INJURY (ICD-584.9) (ICD10-N17.9) New
recheck bmp
Medication List Changes:
Removed medication of MOBIC 15 MG ORAL TABLET (MELOXICAM) 1 po qd; Route: ORAL – Signed
Removed medication of MELOXICAM 15 MG TABS (MELOXICAM) TAKE ONE TABLET BY MOUTH DAILY – Signed
