The purpose of this assignment is to practice evaluating patient encounter notes to identify appropriate Current Procedural Terminology (CPT) codes to submit for billing. This is an important skill to master as an NP.
In this assignment, you are provided with three patient SOAP notes from an encounter with an NP. Using the Required Readings and Required Resources, identify the appropriate code (i.e., 99211, 99212, 99213, etc.) that should have been billed for the visit. In addition, provide detailed rationale on how you came to this decision. Please use the Patient Billing Template (Word).
Patient 1 SOAP note (Word)
Patient 2 SOAP note (Word)
Patient 3 SOAP note (Word)
NU668 Week 4 Assignment 1: Coding
SOAP Note Billing 3
Source: MT (self) and facility staff
MT is an 88-year old white male established patient, who has been in the assisted living facility for the past 2 years. He was living with his oldest son and his family for about 15 years. He said his son kept all his pension and social security money and only gave him $50 every month. He said he finally asked his doctor to help him get a referral for social services when he was hospitalized for a fall incident with no complications or sequela.
He is being seen today for his monthly follow-up visit. He said he feels fine except that he started to have on and off loose stools in the past two weeks. The facility staff put him on diapers to prevent him from soiling his pants.
Subjective: Chief Complaint: Diarrhea
Onset of diarrhea 2 weeks ago. Loose watery brown stools about 2-3 times a day but not every day. Denies blood or mucus in his stool. Denies abdominal pain or cramping. MT said he gets an “accident” sometimes and soils his pants. He said he cannot get to the bathroom on time to have a bowel movement. He said he cannot walk fast enough. Denies urinary incontinence. Denies having eaten any exotic or rotten food. He had not been out to eat in the restaurant. Denies having any antibiotics in the past 2 weeks. Facility staff denies having any gastroenteritis cases in the past two weeks. Denies fever, nausea or vomiting. Denies contact with anyone with same symptoms and denies recent travel. He said he did not take any OTC treatment.
ROS: Denies fever, fatigue or chills; Respiratory: Denies cough; Cardiovascular: Denies palpitations; GI: Denies nausea or vomiting, abdominal pain; Reported diarrhea on and off for the past 2 weeks. GU: Denies urinary frequency, urgency or dysuria
Allergies: No Known Allergies
Current medications: Donepezil 5 mg at HS (started 4 weeks ago with previous follow up visit). Vitamin D3 once daily, Vitamin B Complex once daily, Alendronate 70 mg once weekly
Medical History: Alzheimer’s Dementia; Osteoporosis
Surgical History: Inguinal hernia repair, Cataract surgery with lens implant
Social History: Lives at the assisted living facility. He was married once. His wife died about 17 years ago. He has five children.
Smoking: Never smoked; Alcohol: Denies alcohol use; Coffee: 4 cups a day
Family History: Mother died at age 93 from old age; Father died at age 48 from Malaria complications.
Vital signs: BP 108/72 mmHg Temp: 98.4 F HR: 78 bpm RR: 18 bpm
Height: 70 inches
Weight: 150 pounds
Physical Examination: Alert awake and oriented to person, place and situation; well nourished; Pharynx: Buccal mucosa is moist, no erythema or edema; Respiratory: Lungs clear to auscultation with no adventitious lung sounds; Cardiovascular: Heart rate regular, with no murmurs; Abdomen soft, non-distended, with normal bowel sounds on all four quadrants; no tenderness, no rigidity, no rebound tenderness, no guarding; No CVA; Skin: warm, dry and intact with good turgor. Walks with a cane.
MT is appropriately dressed and well groomed. He has good eye contact and is cooperative. Mood is euthymic with full range affect. He knows the month and the year but does not remember the exact date and day of the week. Speech, language and responses are normal. Immediate recall is 3/3 and delayed memory recall is 1/3. Serial 7’s counting backwards from 100 is accurate. Spelling WORLD backwards is correct. Judgment and insight is good. Perceptual disturbances such as hallucinations and delusions are not observed. MMSE = 26/30
Clock Drawing: Correctly drew an analogue clock with minute and hour hands at 2:45
Assessment: Mild Neurocognitive Disorder due to Alzheimer’s Dementia
The most common side effects of donepezil are nausea, and diarrhea. The prevalence increases with higher doses. The side effects are usually transient and for most patients, the side effects resolve in 2-3 weeks (Rosenblatt, Gao, Mackell, & Richardson, 2010).
1. Infectious diarrhea is caused by enteric pathogens such as bacteria, viruses and parasites. Common pathogens are Vibrio cholerae, Clostridium difficile, Shigella, and Escherichia coli. Examples of parasites are Giardia lamblia and Entamoeba histolytica (Hodges & Gill, 2010). Although the history and pattern of diarrhea appears to be drug-induced diarrhea, infectious diarrhea still needs to be ruled out (Hodges & Gill, 2010).
2. Gastroenteritis is a viral infection of the intestines that usually causes watery diarrhea, abdominal cramps, nausea or vomiting. Sometimes it is accompanied by fever. Many different viruses cause viral gastroenteritis such as rotavirus and norovirus. Most viral gastroenteritis is self-limiting and does not usually last for over 2 weeks ("“Stomach Flu”," n.d.).
3. Functional Diarrhea is chronic diarrhea without a known cause. It is also classified as a functional gastrointestinal disorder (FGD). The Rome III diagnostic criteria for FGD is a change in stool consistency occurring in at least the last 3 months with onset at least 6 months prior to diagnosis. Functional diarrhea is different than Irritable Bowel Syndrome – diarrhea type (IBS-D) due to a lack of abdominal pain that is present in IBS-D (Bolen, 2017). MT has diarrhea on and off for the past 2 weeks.
Plan: Discontinue Donepezil
Labs: Stool C & S; O & P; CBC
Facility staff to report worsening diarrhea
Patient Education: Rehydration therapy
Follow up in 1-2 weeks or sooner as needed. Follow up when lab results are back.
Referral: None as of this time
NU668 Week 4 Assignment 1: Coding
This new patient is a 26-year-old woman who presents to the primary care office complaining of “a sore throat and cold that has gotten worse.” Patent states that her cough has been productive with thick yellow-green sputum. The patient explains that she has a sore throat, stuffy nose, and a fever. Patient estimates that she has had the “cold” for the past three weeks and it has not gotten any better.
Aggravating factors: ambulation (short distances) and smoke.
Relieving factors: cold beverages, cough syrup, cough drops, rescue inhaler one to two times a week, and allergy medicine with minimal effect.
She denies any known sick contacts. She explains that she does not normally get colds that last this long but usually gets them once or twice a year. The patient reports smoking a pack of cigarettes a day and denies alcohol or drug use. The patient has no known diagnosed allergies. No additional concerns at this time.
ROS- Patient denies: chills, travel, headache, chest pain, chest tightness, palpations, wheezing, nausea, vomiting, loose stools, blurry vision, floaters, nausea, vomiting, or loose stools. No foreign body visualized, new bites, flushing, pruritus, anxiety, faintness, blunt force trauma, new foods/ medications/ hygiene products, or sense of impending doom.
Medical history per chart review and patient: asthma, upper respiratory infection on 1/9/17 treated with Z-Pack. The patient denies any cardiovascular issues.
Surgical history: laparoscopic appendectomy 3/23/14, admitted for two days. Familial history, hypertension. The patient is currently employed as a receptionist.
Social History: The patient is single and lives alone in an apartment. The patient is a one pack a day smoker.
Health Promotion: due for pneumonia vaccination (PPSV23).
Medications: Paragard IUD. Albuterol 180mcg oral inhalation two puffs with spacer every six hours as needed for shortness of breath.
General Survey—Alert, friendly, well-kempt woman, good historian.
Vital signs: temperature 98.4, heart rate 114, respirations 25, blood pressure 112/62, SPO2 92% room air.
Head: normocephalic, no lumps or lesions.
Face: symmetrical, no drooping.
Eyes: clear sclera, clear conjunctiva, PERRLA.
Cardiovascular: regular—elevated rate, no rubs, gallops, or murmurs, no jugular vein distention, capillary refill time less than 3 seconds.
Integumentary: skin warm, dry, intact, good turgor. Lap sites scars.
Mouth: lips intact, no caries, moist erythemic mucosa, enlarged tonsils grade 2, no lesions noted.
Nose: no polyps, erythema in both nares, no blisters, petechial, ulcerations.
Throat: erythema, thick yellow-green sputum, no lesions, no difficulty swallowing.
Neck: trachea midline, no nodules, no bruits, no stridor; swollen and tender submental, submandibular, superficial cervical and posterior cervical lymph nodes.
Lungs: tachypnea, coarse inspiratory crackles in right lower lobe, diminished lung sounds in the bases, dullness sound with percussion over right lower lobe; positive tactile fremitus, bronchophony muffled, and egophony abnormal. No nasal flaring, perioral or nail bed cyanosis, sternal, subcoastal, intercostal, or supraclavicular retractions.
Community Acquired Bacteria Pneumonia, RLL
2. Postnasal drip syndrome
3. Acute Bronchitis
Possible organisms: need sputum and nasal cultures to determine organism
Group A beta-hemolytic streptococcus
Group C and G streptococci
Neisseria gonorrhoeae or chlamydia trachomatis
Influenza A, B
Diagnostic tests: rapid strep test, Influenza type A and B swabs, COVID-19 swab. Consider a 2-view chest X-ray (if swabs are negative), and complete blood count with differential.
Pharmacologic interventions: azithromycin 500 mg on day 1 followed by four days of 250 mg a day, acetaminophen 650 mg by mouth as needed for fever of pain or ibuprofen 400 mg by mouth every six hours as needed for fever or pain.
Non-pharmacologic interventions: gargle with warm saltwater (1 tsp salt to 1 cup water), avoid smoking and other respiratory irritants (smoke, automotive exhaust, pollen, dust, dander, strong scents such as perfume), increase nonalcoholic fluid intake, rest, increase room humidity.
Referrals: None at this time. Pulmonology if condition does not improve with oral antibiotics.
Education: side effects of azithromycin, antibiotic teaching about finishing treatment, cough hygiene, fluids, soft foods, when to go to the emergency room, when to call the office.
Follow-up: call the office or go to the nearest emergency room if you have a fever greater than 101, shaking, chills, confusion, blue fingernaisl or lips, have increased cough, difficulty breathing at rest, or increased shortness of breath. Please follow up in the clinic in one week.
NU668 Week 4 Assignment 1: Coding
SOAP Note 1
Age: 25 y.o.
Past Medical history: None
Past Surgical History: Tonsillectomy age 7
Family history: Mother Diabetes, Father Hyperlipidemia
Employment: works as a phlebotomist full time
S: Maria is an established patient who presents to office today for birth control. Pt is in a monogamous relationship with her current boyfriend of 4 months and is using condoms 100% of the time. Pt would like to start a more reliable form of birth control. Menarche 12 y.o menses: every 28 days and lasts for 5 days, patient denies cramps or irregular menses history. Patient is a non-smoker and does not use any substances. Last pap was 6 months ago negative for cytology. Gonorrhea and Chlamydia culture 6 months ago was neg/neg. HPV vaccine completed.
O: 5 feet 6 inches 140 pounds 98.4-80-16-122/76
General: Healthy appearing Hispanic woman in no apparent distress
Skin: No skin lesions identified
Head: Normocephalic, good hair distribution, no alopecia no nits
Eyes: Symmetrical with no erythema or discharge. Vision grossly normal
Ears: Symmetrical with gross hearing intact
Nose: midline, no septal defect, no discharge
Mouth: good dentition, moist mucous membranes
Cardiac: HR 80 normal sinuses rhythm, no S3 or S4, no arrhythmias noted
Lungs: Clear to auscultation bilaterally A & P, no use of accessory muscles
Abdomen: flat, soft, non-distended. Bowel sounds active in all 4 quadrants, tympanic throughout, no hepatosplenomegaly, no rebound or guarding.
A: Contraception Counseling
P: Diagnostics up to date
Education: During the 20-minute face-to-face visit, I discussed with patient the various forms of contraception including barrier, hormonal, non-hormonal, abstinence and natural family planning. Discussed efficacy, cost, risks and benefits of each method, using the Birth control option handout. Discussed timing to start method and how to use method to ensure efficacy. Patient decided to start oral contraceptives. Discussed Sunday start, daily dosing, missed pills, common side effect and major side effects, such as ACHES and when to call.
Continue Condom use for STD prevention
Pharm: Ortho-Tricyclen 28 day, 1 pill every day to start on Sunday after first day of menses. 3 refills
Follow- up: 3 months
NU668 Week 4 Assignment 1: Coding
Please review the three patient visit notes provided and select the appropriate coding level for that visit. In addition, provide rationale for why you chose that code with scholarly support from your required and recommended resources.
References (Use APA 7th edition format)
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