CLINIC NOTE

CC: Patient presents for routine examination

SUBJECTIVE: Sally is a 42-year-old female patient who presents today for a routine physical examination

OBJECTIVE: BP 120/80. Pelvic exam: normal external genitalia. Vagina without discharge except for a scant amount of white discharge that appears normal. Cervix: Multiparous, clear. Bimanual exam is unremarkable. All systems are within normal limits.

ASSESSMENT:
1. Normal BP.
2. Normal pelvic exam.

PLAN: Return in 1 year or as needed.

CPT Code:

99396

Explanation:

CPT Code 99396:

It is a periodic and easy-to-understand precautionary medicine system that are basically well-patient examinations for conventional patients proffering for reevaluations and/or management of the entire health form and fitness with code selection reliant on the patient's age.

These services entails relevant patient history and examination, guidance/recommendation that involves personal predisposing factors, and any laboratory and/or medical diagnosis or procedures that was determined. Clinicians are not expected to outline minimal or self-limiting circumstances or complaints that was stated during the period of the preventive examination when those complications do not need any extra work or demand of carrying out the key constituents of a problem oriented E/M service.

Hope this helps!

she forgot to record a transaction