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Completion of paper Work

Nancy Posted Fri 24th of June, 2011 14:25:35 PM

Please help.
CC Complete paper work
HPI: Pt is a pleasant 77-yr old female, who is here to have her paperwork filled out for ALF placement. She denies any acute medical issues at the present time and states she would like to also schedule an annual physicial exam as she has not had one for some time. She states she is ready for being in an ALF and looking forward to her new home. Denies any depression, anxiety about the impending change.
List of Current Medications
List of Allergies
ROS: All other systems negative except those mentioned above in the HPI.
Physical Findings:
Vitals
General: The patient is a well developed, well nourished, in no acute distress
Eyes: No lesions of the lids or bulbar conjunctive: conjuntivae are without erythema. Ocular exam reveals PERRLA, EOMI. Corneas are clear.
ENMT: EACS are clear without erythema or exudates. Good light reflex with no erythema of the TM's. No bulging or retraction. Hearing is intact to normal speech. nasal mucosa is non-congested, without exudates or epistaxis. Teeth are in adequate repair. no lesions of the buccal mucosa. Tongue is midline. Pharynx is nonerythematous, without exudates. Uvula is midline.
Neck: Supple without masses or tenderness. no thyromegaly of JVD.
Cardiovascular: The BMI is non-displaced. S1, S2, regular rate abd rhythm, without audible murmurs. Cartids without bruits. No abdominal bruits heard. Peripheral pulses present in all extrmities. Extremites without edema, varicosities or cyanosis.
Respiratory: There is no retraction. There is no dullness or hyperresonance to percussion. breath sounds are equal and symmetric. There are no rales, rhonchi or wheezes.
Gastrointestinal: Done
Lymphatic-Done
Musculoskeltal-Done
Skin-Done
Neurological-Done
Psychiatric-Done
I did not give the complete detail of all exams. I do believe you got my drift.
Assessment: Routine f/u for AFL placement and paperwork. The paperwork was filled out and signed by provider after interviewing the patient in detail. Pneumovax done at this time.
Please tell me how you would code this and what dx would you use. Thanking You in advance for your help.

SuperCoder Answered Fri 24th of June, 2011 19:58:05 PM

We need to code preventive medicine services for established patient visit, as the exam seems to be complete.

SuperCoder Answered Fri 24th of June, 2011 20:01:49 PM

Looks justified, but there are variations also. Billing as Preventive if gets paid, then would cause denial for the due Annual Physical Exam to be performed in recent future.
Since this is a medicare patient, and the patient's annual physical exam is due, hence it would be proper to bill now with Office Visits with ICD V70.3

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