Established Office Visit #1 (Primary Care)

Primary Care Established Office Visit #1

Chief Complaint: Medication refill, routine checkup chronic problems. (Chief Complaint is present, but documentation is not ideal)

History of Present Illness: This 86-year old white male is here for his medication refills. He denies any complaints. (denies complaints = severity, quality or lack of severity, quality)

Medications: He is currently taking Norvasc 2.5 mg daily, Lopressor 50 mg bid, Lotensin 40 mg daily, hydrochlorothiazide 25 mg daily, Lescol 20 mg daily, Ocuvite, betacarotene, zinc and multivitamin. (PFSH = Past Medical History)

Allergies: He is allergic to penicillin and procardia. (PFSH = Past Medical History)

Brief HPI (1 HPI) + No ROS + Pertinent PFSH (1 area) = PROBLEM FOCUSED HISTORY

(95 EXAM) (97 GMS EXAM)

Physical Examination:

CONSTITUTIONAL Heart rate: 52, BP: 124/58. This 86 yo well-nourished make is in no apparent distress. (1 bullet for general appearance) (no other bullet, only 2 vitals) PSYCH He is alert and oriented x 3. (1 bullet for Psych, orientation to time, place, person) EYE. ENT HEENT: Unremarkable exam. (0 bullets, not specific enough to assign bullet) RESPIRATORY Lungs: clear to auscultation and percussion bilaterally. (1 bullet for ausc lungs) CARDIOVASCULAR Heart: Remains with murmurs that were noted before in Dr. Cardiology’s physical exam. (1 bullet for ausc heart) GASTROINTESTINAL Abdomen: Soft, nontender. No guarding, rigidity or organomegaly. Bowel sounds are present in all 4 quadrants. (1 bullet for exam abd)

95 CMS EXAMINATION = 7 SYSTEMS = EXPANDED PROBLEM FOCUSED EXAMINATION (Per DG presenting problem system must be detailed. No presenting system documented) 95 WPS EXAMINATION = 7 SYSTEMS = DETAILED 97 GMS EXAMINATION = 5 bullets = PROBLEM FOCUSED EXAMINATION Discharge Instructions: I discussed this case with Dr. Cardiology (MDM Data Review = 2 pts discussion with other healthcare provider) and we are sending him for (MDM Data Review = 1 pt order/review labs) electrolyte-7 and PSA. Other than that he will follow up with Dr. Cardiology in 2 months. (MDM Risk = Moderate = Presc Drug Management) I refilled all of his prescriptions.

MDM = 1 pt for # Dx or management options (murmur) + 3 pts Data Review for discussion of case with another healthcare provider and review/order labs, + Moderate Risk for prescription drug management = MODERATE MDM

CMS 95 DG Problem Focused HPI + Expanded Problem Focused Exam + Moderate MDM = 99213

CMS 97 DG Problem Focused HPI + Problem Focused Exam + Moderate MDM = 99212

WPS Problem Focused HPI + Detailed Exam + Moderate MDM = 99214

ICD-9 Coding:

1. Prescription Refills: V68.1 Admission for: Issue of repeat prescription

2. Murmur: 785.2 Murmur noted in exam and discussed with Cardiology. FU with cardiology recommended.