Please review this document and tell me if I'm wrong with coding this at 99214. Thank you
Primary Provider:
CC: Possible UTI.
History of Present Illness:
1.5 weeks of cramp like pelvic pain that started on Lt side then Rt side started to hurt and now center of pelvic. Denies fever/chills, nausea or vomiting. Denies vaginal discharge or spotting. FDLMP was 02/12/2015 was only 2 days and was light. Usual period is 5 to 7 days. Sexually active with one partner.
Has had tubal. Hx PID per pt
Pt is over due for her annual pap and pelvic.
Past Medical History:
Reviewed history from 11/05/2014 and no changes required:
Patient indicates medical history of
+pneumonia 1985,
seizure 1981.
cervical dysplasia;
history of drug abuse- narcotic and meth
depression/anxiety
Past Surgical History:
Reviewed history from 02/04/2013 and no changes required:
Patient reports surgical history to include: tubal ligation. LEEP procedure; oral surgery
Family History:
Reviewed history from 02/20/2013 and no changes required:
The patient indicates family history of stroke (grandfather, grandmother), coronary artery disease (grandfather, grandmother), hypertension (mother), diabetes (grandfather), asthma (grandmother), COPD (grandmother), substance abuse (father), thyroid disease (mother). Other family history includes: cervical cancer- aunt on maternal side.
Risk Factors:
Tobacco use: current every day smoker
Review of Systems
General
Denies fever, chills, fatigue, and weight loss.
GI
Complains of abdominal pain.
Denies nausea, vomiting, and change in bowel habits.
GU
Denies urinary frequency, urinary urgency, painful urination, and unusual urinary color.
Vital Signs:
Patient Profile: Old Female
Height: 62 inches (157.48 cm)
Weight: pounds
Pulse rate: 72 / minute
Pulse rhythm: regular
Resp: 18 per minute
BP sitting: 110 / 70 (left arm)
Cuff size: regular
Vitals Entered By:
Physical Exam
General:
well developed, well nourished, in no acute distress.
Head:
normocephalic and atraumatic.
Lungs:
clear bilaterally to auscultation.
Heart:
regular rhythm, normal rate, and no murmurs.
Abdomen:
normal bowel sounds; no hepatosplenomegaly no ventral,umbilical hernias or masses noted. suprapubic tenderness.
Laboratory Results
Date/Time Collected: 02/24/2015
Routine Urinalysis
Color: yellow
Appearance: clear
Leukocytes: negative
Nitrite: negative
Urobilinogen: 0.2
Protein: negative
pH: 6.0
Blood: negative
Spec. Gravity: 1.015
Ketone: trace (5)
Bilirubin: negative
Glucose: negative
Impression & Recommendations:
Problem # 1: PELVIC PAIN (ICD-789.09)
Assessment: Unchanged
Pt had childern with her and will re schedule for pap and pelvic in the next week or so.
Orders:
Chlamydia & Gonorrhoeae Aptima (APTCG)
Needs some input on E/M Level
