Don't have a TCI SuperCoder account yet? Become a Member >>

Regular Price: $24.95

Ask An Expert Starting at $24.95
Have a medical coding or compliance question? Don’t sacrifice your valuable time to endless research. Choose Ask an Expert to get clear answers from the TCI SuperCoder team. And here’s a tip for the budget-conscious: Select the 12-question pack to get the best rate per question!

Browse Past Questions By Specialty

+View all

G0402 or G0438 with 99214

Elena Posted Wed 11th of December, 2013 17:33:20 PM

Need additional opinions to help me decide if documentation is supportive of both G0402or G0438 and 99214.
Please note that a complete ROS and History was done, just wont copy over.

Reason for Appointment
1. Pap
2. Would like shingles vaccine script, and pneumonia vaccine
3. Dysmenoria

History of Present Illness
Gen:
65 yr-old WF in for physical
Issues:
1. colon polyps: needs repeat scope
2. "sexually dysfunctional" due to dyspareunia, atrophy
3. tob abuse
4. depression: wants to wean off meds
5. acne: wants retinA
see ROS.
* Gen:
Pt presents for Medicare physical; see ROS.

Vital Signs
Ht 5 ft 1.3 in, Wt 128, BMI 23.95, BP sitting 116/78, HR 80, Temp 97.8, RR 18.

Examination
TAW:
Gen + in no acute distress, + well developed, well-nourished. Head NC/AT. Eyes conjuctiva normal, no drainage. Ears normal. no drainage, no lesions, no gross blood. Face no rashes. mouth no abnormalities. Throat normal posterior pharynx. Neck no thyromegaly, no JVD, no carotid bruit appreciated, no lymphadenopathy. CV RRR without M/G/R. Lungs CTA bilat, normal effort. abd soft, NT, ND, + BS. ext no C/C/E, normal color. psych normal affect. skin warm, dry, good turgor. Neuro AAO x 3, no S/M deficits noted. Gyn no discharge, normal odor, no CMT, vault normal, cervix well visualized, normal adnexal exam. Breasts no masses, lumps, no dimpling, no nipple discharge. speech normal.

Assessments
1. Complete Physical Exam - V70.0 (Primary)
2. Cervical cancer screening - V76.2
3. screening for HTN - V81.1
4. Screening for hyperlipidemia - V77.91
5. screening for ischemic heart dz - V81.0
6. Screening for hypertension - V81.1
7. screening for other CV conditions - V81.2
8. Fatigue - 780.79
9. DM screening test - V77.1
10. immunization for pneumo - V03.82
11. Special screening for malignant neoplasms, colon - V76.51
12. Encounter for screening for cardiovascular disorders - V81.2
13. Osteoporosis screening - V82.81
14. Breast Ca screening, non-mammo - V76.10
15. Breast cancer screening - V76.10
16. Living will, counseling/discussion - V65.49
17. Depression - 311
18. Acne - 706.1
19. Vaginal atrophy - 627.3
20. Dyspareunia - 625.0
21. Tobacco Abuse - 305.1
22. Tobacco abuse counseling - V65.42

Treatment
1. Complete Physical Exam
LAB: Urinalysis w/scope
Reviewed all info above on Medicare Preventative Services with pt; labs, immunization status done/reviewed.

2. Cervical cancer screening
LAB: Pap IG, rfx HPV ASCU
LAB: Lipid Panel With LDL/HDL Ratio
LAB: Comp. Metabolic Panel (14)
LAB: Pap 1 Slide
LAB: CBC With Differential/Platelet

3. screening for HTN
Diagnostic Imaging:EKG for IPPE
check labs.

4. Screening for hyperlipidemia
LAB: Lipid Panel With LDL/HDL Ratio

5. screening for ischemic heart dz
check labs.

6. Screening for hypertension
LAB: Comp. Metabolic Panel (14)

7. Fatigue
LAB: CBC With Differential/Platelet

8. DM screening test
check labs.

9. Osteoporosis screening
Diagnostic Imaging:Bone Density

10. Breast cancer screening
Diagnostic Imaging:Mammogram

11. Living will, counseling/discussion
pt already has.

12. Depression
Refill Paroxetine HCl Tablet, 20 mg, 1 tablet in the morning, Orally, Once a day, 90 days, 90, Refills 1
pt will wean over 4-6 weeks.

13. Acne
Start Retin-A Micro Gel, 0.1 %, 1 application to affected area in the evening to face, Externally, Once a day, 90 DAYS, 1 bottle, Refills 2

14. Vaginal atrophy
Start Vaginal Lubricant Suppository, 1, as directed, Vaginal, q day x 1 week then 2 times a week, 90 DAYS, 30, Refills 0
discussed in detail; will try above.

15. Tobacco Abuse
Start Chantix Starting Month Pak Tablet, 0.5 MG X 11 & 1 MG X 42, as directed, Orally, as directed, 30 days, 1, Refills 0
Counseled Patient for 3 minutes on the dangers of smoking and different cessation products available. Pt doeswish to quit smoking at this time.; will try above.

16. Others
Referral To:Kathleen Raynor Gastroenterology
Reason:hx polyps, needs scope

Immunization
Pneumonvax : 0.5 mg given by Burris, Nicole on left deltoid

Procedure Codes
99214 Office Visit
90732 Pneumococcal
G0402 initial preventive physical exam
81003 UA without micro
G0403 EKG for IPPE
G0101 CERV/VAG CANCR SCR;PELV&CLN BRST EX
Q0091 screening pap

SuperCoder Answered Thu 12th of December, 2013 15:22:27 PM

Don't code a separate office visit code of 99214. This is documented as an annual wellness visit so use the appropriate G code for Medicare patient.

Related Topics