I have a provider who billed a 99214 for the below encounter.
What conditions would you count as managed and do you think this would qualify as a 99214?
CC: PT here for check up
HPI: He is here for a check-up. Work has busy. His active. Has a varied diet.
Glucose readings are <200. No hypoglycemia.
He has been more tired. Has been drowsy. Has restless sleep. Has nocturia. Possibly snores. No temperature intolerance. No fever.
No chest pain. No SOB. No DOE. No orthopnea. Urine flow is reduced. Flomax has helped. Is followed by Urology. Has urgency. Normal BM’s.
Did try Phentermine for wt loss. Did affect his sleep.
Diabetes Type II (Follow-Up): The patient states he has been stable with his Type II Diabetes control since the last visit.
Constitutional: No fever
Cardiovascular: no chest pain
Respiratory: no dyspnea
General appearance: No acute distress, well appearing and well nourished.
Head and Face
Head and face: Atraumatic, normocephalic.
Conjunctiva and lids: No erythema, swelling or discharge.
Pupils and irises: Equal, round, reactive to light, sclera anicteric.
Ears, Nose, Mouth, and Throat
External inspection of ears and nose: Normal.
Otoscopic examination: Tympanic membranes translucent with normal light reflex. Canals patent without erythema.
Oropharynx: Normal with no erythema, edema, exudate or lesions.
Neck: Supple, symmetric, trachea midline, no masses.
Thyroid: No thyromegaly, tenderness or palpable nodules.
Respiratory effort: No increased work of breathing or signs of respiratory distress.
Auscultation of lungs: Breath sounds equal and clear bilaterally.
Auscultation of heart: Regular rate and rhythm without murmurs, rubs, or gallops.
Examination of extremities for edema: No significant edema.
Abdomen: Soft, non-tender, non-distended, no masses and normal bowel sounds.
Liver and spleen: No hepatomegaly or splenomegaly.
Palpation of lymph nodes in neck: No lymphadenopathy.
Muscle strength/tone: Normal.
Cranial nerves: Cranial nerves 3-12 intact.
Detailed Diabetic Foot Screening (smg):
Right Foot: the foot was normal.
Left Foot: the foot was normal.
Monofilament Testing:. normal tactile sensation with monofilament testing throughout both feet.
1. Encounter for preventive health examination
2. Benign Prostatic Hypertrophy
6. Type 2 Diabetes Mellitus
Diabetes, Type 2
• Microalbumin with Urine Creatinine
• Foot Exam
• Start Metformin HCl ER 500 MG Oral
• Start Victoza 18MCG/3ML Subcutaneous Pen Injector
• Renew Levoxyl 88 MCG Oral Tablet
• Renew Atorvastatin Calcium 20 MG Oral
• Renew Fenofibrate 145 MG Oral
• Start Phentermine HCl 37.5 MG Oral
Discussion/Summary: Active Problems, Current Meds, Allergies, Past Medical History, Surgical History, Family History and Social History were reviewed and updated as clinically indicated. The findings of today's visit were discussed with the patient. Medications will be changed as noted above. Risks and benefits of the medication changes were discussed with the patient. He will have the above tests performed and will be notified of the results. He is instructed to call with any problems. Offered sleep study. Discussed diet and weight.
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