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Case 10 Psychiatry Re: Victoria K. Burns MR = 700-10 Date of Service: January 5, 20XX Anxiety Patient is accompanied by her husband. Both agree she has been improving. No manic symptoms. She also continues lithium and Effexor regularly as prescribed. Again, neither feel changes in psychotropics are needed. She continues part-time at the School. She won’ t work there this summer due to low enrollment. Physical health remains good, no suicidal ideations. Her PCP of record is Dr. Henry, although she has not seen her yet. I encouraged her to make an appointment and establish care. Discussed my retirement at the end of this year and follow-up care options. Medications: Seroquel (QUEtiapine Fumarate) 100 MG Tablet 1/2 or 1 at bedtime Lithium Carbonate 300 MG Capsule 1 twice daily Effexor XR (Venlafaxine HCI ER) 37.5 MG Capsule Extended Release 24 Hour 1 capsule with food daily Medication List reviewed and reconciled with the patient Surgical History: C section 19XX, 19XX, 19XX Arthroscopic knee surgery 20XX Hand surgery 9/20XX Tobacco Use: Smoking Status: never smoked Smokeless Tobacco Current user: No Former user: No Mental Status Exam: APPEARANCE: average height and weight, appropriate dress and grooming. appears stated age. ORIENTATION: alert and oriented MOOD euthymic. AFFECT: normal range. BEHAVIOR: no abnormalities. SPEECH: normal. INSIGHT fair. THOUGHT PROCESSES: logical and coherent. MEMORY PROBLEMS: grossly intact. THOUGHT CONTENT: denies SI and Hi, no psychotic symptoms. EYE CONTACT: normal. ATTENTION; tracks okay INTELLECT: average. JUDGEMENT: fair. ATTITUDE: appropriate, pleasant 1. Bipolar disorder, in full remission Refill Seroquel Tablet, 100 MG, 1/2 or 1 at bedtime, 90, Refills 1 Refill Lithium Carbonate Capsule, 300 MG, 1 twice daily, 180, Refills 1 Refill Effexor XR Capsule Extended Release 24 Hour, 37.5 MG, 1 capsule with food daily, 90, Refills 1 Clinical Notes: Discussed my retirement in December. Encouraged her to establish with a PCP. Retum 6 months Electronically signed: Patient Name Medical Record Number/Account Number Provider Insurance Company Comments Psychiatry Coding Fee Ticket Victoria K. Burns 700-10 Ava Bell, DO United Behavioral Health Date of Service 1/5/20XX Facility Place of Service 二 CPT” Code(s) 99213 Diagnosis Code(s) F31.73 Modifier Quantity AAPC Physician Group Total 2. What discrepancies have been identited? A. Ine procedure coue is reported incorrectly and billed under the wrong provider. The document was not signed by the provider, and the diagnosis code was reported incorrectly. The procedure and diagnosis codes are reported incorrectly. The procedure code and diagnosis code are reported incorrectly and billed under the wrong provider.
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