Clinical Decision-Making NU671. Unit 2New Patient Encounter. Due 11-8-2. 800w.4 references.
Initial Response
Instructions:
Consider the following questions in your initial discussion post:
· Review the SOAP note accessed through this link. For purposes of the assignment, the patient is a ‘new patient’ in the practice.
·
New Patient SOAP Note
Download New Patient SOAP Note
Download New Patient SOAP Note
Initial Post
Use your lecture materials to determine what CPT E&M Code to utilize for this ‘new patient’ encounter.
You may choose to assign the code based on the anticipated/guestimate amount of time the provider would spend with the patient in the encounter or you may choose to utilize the Medical Decision Making (MDM) approach. If you choose the MDM include the following information in your discussion:
1. the level of history taking achieved – identify the history elements present
2. the type of exam performed – identify the number of systems and bulleted points in the note
3. the level of medical complexity encompassed – include # of points for a) diagnoses/management options, b) amount/complexity of data reviewed, and c) level of risk for complications, morbidity, mortality
Please be sure to validate your opinions and ideas with citations and references in APA format.
SOAP notes provided by the instructor for this assignment
Chief Complaint:
“I don’t know how much longer I can go on like this. I’ve been down in the dumps for years and it isn’t getting any better.”
History of Present Illness:
75-year-old white male present to clinic with above complaint. Lost his first, the “love of his life” wife 19 years ago. Remarried 2 years after her death and states he probably married again too soon reporting his current wife is difficult. He describes an instance, when he was at work, the second wife would not let his son, daughter-in-law and new grandbaby into his house to visit until he got home from work. The second wife also insisted that he no longer visit with his deceased wife’s family telling him ‘when you married me, you divorced that whole family’. Conversations with his wife about his concerns resulted in only short-term changes in her approaches and behaviors. Now his wife insists they sell the house he has lived in for 46 years. He reports that his memory and ability to make simple decisions have been deteriorating significantly over the last several months. His wife suggested he probably has Alzheimer’s and should go see his primary care provider about his memory issues. He reports that he engages with modest exercise daily, eats well but is waking up numerous times at night and is usually “up for good” by 5am. He blames his disrupted sleep pattern on his feeling of fatigue starting around 9am. He reports all these circumstances as contributing to his increased depression and his desire to “give up the fight”.
PMH:
reports usual childhood illnesses inclusive of measles, mumps and chickenpox
traumatic injury, likely secondary to ‘blast’ effect, sustained during the bombing of Pearl Harbor where he was stationed as a cook; he suffered a hearing loss for six months after the bombing and was diagnosed at 54 with a rare eyes disorder resulting in poor peripheral vision that is thought to be secondary to this trauma
Family Hx:
Father died at 67 secondary to colon cancer; mother died at 24 secondary to influenza during an epidemic (he was 2 years old at that time)
No know family history of depression or other mental illness
Social Hx:
HS graduate, married to HS sweetheart for 27 years then widowed
Current marriage of 17 years
Retired after 25-year banking career
Attends Catholic mass regularly
Drinks 1-2 beers several times a week, denies episode of intoxication; never smoked or used illicit drugs
Drinks hot tea, reporting coffee causes too much GI distress
Never driven a motor vehicle secondary to poor peripheral vision
ROS:
Denies HA, body aches, dizziness, fainting spells, tinnitus, ear pain, ear discharge, nasal congestion, diarrhea, constipation, change in appetite skin abnormalities, or genitourinary symptoms
Denies periods of extreme irritability or elation associated with periods of sadness; denies feeling more depressed during the winter months than other seasons
Reports fatigued most of the time, often feels stiffness in his neck and shoulders
Denies homicidal ideations, hallucinations, paranoia or delusions
Reports suicidal thoughts, has a 22-caliber rifle at home and has considered using to end his life
SIGECAPS:
Reports – poor sleep maintenance, loss of pleasure, he feels as though he remarried too soon, he is experiencing fatigue, he is experiencing memory disturbances, eating well, no problems maintaining exercise regimen, is having suicidal ideations
Medications:
No routine medications
Allergies:
None
Physical Examination:
Constitutional – BP 118/73, P 83, RR 16, T 98.8, Ht 71 in, Wt 174 lbs, BMI 24
Integument – skin, hair and nails unremarkable
HEENT – PERRLA, EOMs intact, nares patent without discharge noted, TMs gray and shiny bilateral, numerous silver amalgams noted
Neck – supple without adenopathy, no thyromegaly
Lungs – CTA
Heart – RRR without murmur/gallop
Abdomen – soft, non-distended, active bowel sounds, non-tender, no organomegaly
Genitalia/Rectum – deferred
Musculoskeletal – no gross abnormalities or major limitations of ROM noted
Neurologic – CNs II-XII intact, finger-to-nose test negative, DTRs 2+ and equal bilateral, sensory capacity intact upper and lower extremities intact bilateral
Mental status – PHQ 9 score is 19
Diagnostics – Na 138 meq/L, K 4.2 meq/L, Cl 102 meq/L, HCO3 27 meq/L, Bun 11 mg/dL, Cr 0.9 mg/dL, fasting Glu 106 mg/dL, Ca 9.5 mg/dL, Mg 1.8 mg/dL, AST 34 IU/L, ALT 42 IU/L, GGT 38 IU/L, Alb 4.4 g/dL,
TSH 2.8, Vit B12 98 pg/mL, Folic acid 333 ng/mL, PSA 4.9 ng/mL, Hgb 14.3 g/dL, HCT 41.4 %
Urine dipstick – 5.8 pH, SG 1.016, all other parameters negative
Assessment:
1. F32.1 Major depressive disorder, single episode, moderate
2. R45.851 Suicidal ideations/thoughts
3. R73.03 Prediabetes
4. E53.9 Vitamin B deficiency
Plan:
1. Major depressive disorder
a. Diagnostic – none
b. Therapeutic – citalopram 20mg take 1 by mouth daily dispense #30 with 2 refills
c. Educational – effects of citalopram may not be fully evident for up to 3 or 4 weeks; if you note fatigue exacerbated from the citalopram take it at bedtime; RTC in 1 month for follow up
d. Consultation/Collaboration – none
2. Suicidal ideations/thoughts
a. Diagnostic – none
b. Therapeutic – same as diagnosis #1
c. Educational – same as diagnosis #1; educate on the potential negative impact of his current intake of beer – educate on how to safely reduce this consumption and to avoid abrupt cessation; educate on need to remove the 22-caliber rifle from his home; provide information on suicide hot lines
d. Consultation/Collaboration – referral for counseling
3. Prediabetes
a. Diagnostic – none
b. Therapeutic – none
c. Educational – nutrition education aimed at making dietary lifestyle choices of low glycemic index foods (<55 GI) that aid in development and maintenance of stable insulin and glucose levels
d. Consultation/Collaboration – none
4. Vitamin B deficiency
a. Diagnostic – none
b. Therapeutic – hydroxocobalamin 1000 mcg IM during this OV; start on 2mg oral B-12 daily; recheck Vitamin B-12 level in 2 to 3 months
c. Educational – nutrition education on foods high in B-12
d. Consultation/Collaboration – none
Sample assignments
New Patient Encounter
SOAP Note Review
This type of note is used in medical or psychological sectors by professionals while
working with clients or patients. In the note provided, the patient presents a persistent rash as the
chief complaint .The rash was first in the chest but has recently spread to the arms, and it is not
itchy and painful. He has had Hypoglycemia in 2010 and an allergy to NKDA. He has no
frequent medications and occasionally uses OTC NSAIDS if he has minor pain .The new patient
is married and smokes a packet per day, six-pack beer daily, and denies any chemical drugs use.
His history indicates his father and mother, are deceased due to cardiac issues. His paternal
grandmother had Cardiac died at 78, and his grandfather also had a Stroke. His maternal
grandmother had diabetes type 2 and is 75. The review of systems reveals that has no issues with
the targeted aspects.
His physical examination indicates a weight of 197, height 74.5 in, BMI 25.05 blood
pressure 130/86, and temperature at 98.9 PR 70 RR 18. The patient is alert and has
hyperpigmented muscles on both arms. The head, eyes, ears, nose, and throat (HEENT)
examination show normality in every aspect .The chest cavity, GU, lungs, abdomen, and other
diagnostics do not indicate any abnormalities. He is diagnosed with Tinea Versicolor at B36.0
and alcohol abuse at F10.10. His treatment plan involves Tinea versicolor Therapeutics in which
he is to apply Ketoconazole 2% external shampoo on the affected skin for three days. The patient
is enlightened about using the medication as prescribed and asked to report if the symptoms
persist or worsen. The are no diagnostics for alcohol abuse, but he was educated on the risks of
taking alcohol while on medication and its effects on the liver and advised not to quit cold
Turkey.
Selection of CPT E&M Code
The CPT E&M code to utilize in this scenario is 99201 since the encounter is with a new
patient and is likely to take 45 minutes (Babac, et al., 2019).This code is best since it covers the
entire patient history and examination and moderates the medical decision-making process
(Cohen, et al., 2020).Various diagnoses will be undertaken, and management options and the
complexity of data involved is moderate, and the risk of complications is medium.
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References
Babac, A., Von Friedrichs, V., Litzkendorf, S., Zeidler, J., Damm, K., & Graf von der
Schulenburg, J. (2019). Integrating patient perspectives in medical decision-making: A
qualitative interview study examining potentials within the rare disease information
exchange process in practice. BMC Medical Informatics and Decision
Making, 19(1). https://doi.org/10.1186/s12911-019-0911-z
Cohen, B. H., Busis, N. A., Villanueva, R., & Ciccarelli, L. (2020). Evaluation and Management
Codes for Outpatient Neurology Services in 2021: Changes to 99202-99215. Continuum:
Lifelong Learning in Neurology, 26(6), 1686-1697.
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New Patient Encounter
The comprehensive assessment and examination of patients with mental disorders differ
greatly from the comprehensive assessment and examination of patients who are suffering from
physical disorders. Mentally ill patients require extensive evaluation, detection of severity of
symptoms, in-depth analysis of thought process, ideologies and perceptions. The implementation
of tools, interview questions and evaluation of results are time consuming. All these components
demand adequate time investment of psychiatrist and if the patient is new then the analysis and
evaluation takes more time as compared to those patients who came with established complains.
Considering these facts, the CPT E&M code for this new patient is 99205. The provided reading
resources for this module also indicated that the total time spent with a new patient should be 60
to 74+ and therefore the designated code should be 99205. I have not selected other codes
associated with new patient encounter (that is, 99202, 99203 and 99204) because the presented
case study is a complicated case that requires evaluation of depressive symptoms, their severity
and severity of suicidal thoughts and ideation (Melnyk, 2020).
The patient also reported that he desires to “give up the fight” which indicates that he
possesses thought processes related to suicides as he mentioned the presence of 22-caliber rifle at
home and shared his feelings to end his life by using that rifle. Furthermore, patient is also
suffering from physical disorders like prediabetes, sleep issues, fatigue and loss of appetite. All
of these symptoms indicate that the patient requires extensive evaluation and monitoring.
Although, he is a new patient but the follow visits would also require the implementation of code
99204 in order to continuously monitor improvement in symptoms and progress of disorder and
treatment. If the follow up visits for this patient requires implementation of 99204 code then it is
mandatory to implement the code of 99205 to his first visit (Modrek, Hamad & Cullen, 2015).
References
Melnyk, B. M. (2020). Reducing healthcare costs for mental health hospitalizations with the
evidence-based COPE program for child and adolescent depression and anxiety: A cost
analysis.
Journal of Pediatric Health Care,
34(2), 117-121.
Modrek, S., Hamad, R., & Cullen, M. R. (2015). Psychological well-being during the great
recession: Changes in mental health care utilization in an occupational cohort.
American
Journal of Public Health,
105(2), 304-310.
Response 1
Hello Brittney,
Each year, in the United States, healthcare insurers process over 5 billion claims for
payment. To ensure that healthcare data are captured accurately and consistently and that health
claims are processed properly for Medicare, Medicaid, and other health programs, a standardized
coding system for medical services and procedures is essential. The Current Procedural
Terminology (CPT) system, developed by the American Medical Association (AMA), is used for
just these purposes. The AMA system provides a standard language and numerical coding
methodology to accurately communicate across many stakeholders, including patients, the
medical, surgical, diagnostic, and therapeutic services provided. The CPT descriptive
terminology and associated code numbers provide the most widely accepted medical
nomenclature used to report medical procedures and services for processing claims, conducting
research, evaluating healthcare utilization, and developing medical guidelines and other forms of
healthcare documentation (Pelech & Hayford, 2019).
Reference Pelech, D., & Hayford, T. (2019). Medicare advantage and commercial prices for mental health
services.
Health Affairs,
38(2), 262-267.
Response 2
Hello Lorilee,
The Current Procedural Terminology (CPT) code set describes tests, evaluations,
treatments, and other medical procedures used in the spectrum of healthcare. The set contains
over 8,000 codes and is published and updated annually by the American Medical Association. It
was created to track healthcare trends and issues as well to use in the claims submission process.
The codes communicate to payers what procedures should need to be reimbursed for as a
provider. The codes related to mental health (codes 90785-90899) are found in the Psychiatry
section of the CPT code set and cover services provided by medical professionals, such as
psychiatrists, as well as services that can be delivered by non-medical professionals such as
licensed clinical psychologists, licensed professional counselors, licensed marriage and family
therapists, and licensed clinical social workers (Powell, Torous, Firth & Kaufman, 2020).
Reference
Powell, A. C., Torous, J. B., Firth, J., & Kaufman, K. R. (2020). Generating value with mental
health apps.
BJPsych Open,
6(2).
