E/M Coding Rounds Case of the Week: 6/18/08
Is this really a level-four office visit (99214)?
CC: HTN and dyslipidemia.
INTERVAL HISTORY: The patient feels fine. He has no somatic complaints.
Medications: amlodipine 10 mg PO QD, simvastatin 10 mg PO QD
PHYSICAL EXAMINATION: GENERAL: NAD; looks stated age. BP 164/82, HR 84, RR 18. Eyes: Anicteric sclerae. Neck: No JVD or carotid bruits. Lungs: CTA with normal respiratory effort. CV: RRR with no MRGs; normal PMI in the MCL. ABD: Soft, non-tender; normal aortic pulsations. EXT: No peripheral edema; brisk, symmetric pedal pulses.
LABORATORY INFORMATION: LDL 77, HDL 54
- Poorly controlled HTN.
- Stable dyslipidemia.
- Continue simvastatin
- Continue amlodipine
- Add lisinopril 20 mg PO QD
- RTC in six weeks with renal profile and LFTs.