I need help finding them E&M code for this:
HISTORY OF PRESENT ILLNESS: Mr. Smith is a 63-year-old gentleman new to our Clinic. He had been followed by Dr. Jones at Kernodle Clinic. Mr. Smith has a past medical history that includes hypertension for more than five years. It sounds like he has fairly severe white coat hypertension. Apparently, he has home readings consistently 30 points below what he gets in the office. He had been on Capoten in the past and gotten a cough with that. He had been on Norvasc in the past, but then stopped it for unclear reasons. More recently, he has been on Hyzaar. He also has hypercholesterolemia and has been on Lipitor. He has for the past year or so felt that his hands and feet were “burning up” at night. He reports that “he can almost see the heat waves from them.” He thinks this is a medication side effect. On his own, he stopped his Lipitor three weeks ago. He has not noticed any difference in his symptoms. He otherwise feels well and has no complaints.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Status post plastic surgery after a motor vehicle collision when he was in his 20s. 4. History of depression around the time of the accident. He does report that intermittently he feels quite down, but he is able “to pick himself back up”. More recently, however, he has been in a more prolonged period. 5. He has significant moles and he is followed by an outside dermatologist. 6. He has had normal PSA and rectal exams. He had a colonoscopy about five years ago and again one year ago, both of which showed many polyps, pathology not known.
MEDICATIONS: Now only Hyzaar, a baby aspirin and a multivitamin
ALLERGIES: Capoten caused a cough.
SOCIAL HISTORY: He works in computer software. He does not smoke. He drinks wine and Martinis “probably more than I need to.” No drug use.
FAMILY HISTORY: The patient’s father died of a brain aneurysm in his 50s. Mom had colon cancer in her 80s and also hypertension. Five older sisters all with hypertension and hypercholesterolemia. No known coronary artery disease.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fevers. Weight up 15 lbs since March. HEENT: Teeth doing okay. Does not feel congested in his sinuses. CARDIOVASCULAR: No chest pains, palpitations, PND, orthopnea or edema. RESPIRATORY: No shortness of breath. He does have a chronic intermittent cough that he has had for years. He had a chest x-ray a couple of years ago to evaluate this which was apparently normal. GI: No abdominal pain. No reflux-type symptoms. No change in bowel habits. GU: No hematuria or dysuria. MUSCULOSKELETAL: No chronic joint pains. PSYCHIATRIC: Not suicidal.
VITAL SIGNS: Weight 86.7 kg which is 191 lbs, blood pressure 174/114, pulse 103.
HEENT: Conjunctivae pink. Sclerae anicteric. Oropharynx clear.
NECK: No lymphadenopathy or thyromegaly or JVD.
LUNGS: Clear to auscultation and percussion.
HEART: Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN: Normal bowel sounds. Soft, nontender. No hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing or edema.
PSYCHIATRIC: Normal affect and behavior with seemingly good insight.
ASSESSMENT AND PLAN:
- Hypertension, poor control even with supposed white coat hypertension. He again is worried about side effect of his medications. We talked about many options and decided to change him to HCTA 25 mg a day and Norvasc 10 mg a day.
- Hypercholesterolemia. We will check lipid panel today. We will hold off on Lipitor for now, but will likely restart this once we confirm he is not having drug side effects. He is also interested in possibly trying fish oil.
- Psychiatric. He was not interested in counseling at all. He was interested in medication. We will start Celexa 20 mg a day. He will titrate this up to 40 mg after three to four weeks. He will call us in a few weeks if he is having any problems.
- Health maintenance. We will hold on PSA screening for a bit as he has been screened in the past. We will repeat colonoscopy in a few years and will try to get records of prior polyp pathology. He will try to focus on drinking a bit less alcohol and getting some regular exercise and eating better. Continue baby aspirin.
- Return to clinic in two months.
John Student, MS3
Seen with Joe Doctor, MD