Assessment Section:
# Routine general medical examination at a health care facility (Z00.00):
AWV: Initial, peformed. The plan of care is as follows in the plan section.
Cognition: Recall of three words normal.
Depression Score:
Over the past two weeks, have you felt down, depressed, or hopeless?
Over the past two weeks, have you felt little interest or pleasure in doing things?
Functional Ability: Normal Up & Go test, normal ADL screen, normal walk safety screen, normal hearing screen.
Was the patient's timed Up & Go test unsteady or longer than 30 seconds?
Do you need help with the phone, transportation, shopping, preparing meals, housework, laundry, medications, or managing money?
Does your home have rugs in the hallway, lack grab bars in the bathroom, lack handrails on the stairs, or have poor lighting?
Have you noticed any hearing difficulties?
Do you want an EKG? (CPT G0403, G0404, G0405)
All of questions %Mr %LNAME had were answered.
Coding
IPPE G0402 (Welcome to Medicare) age 65 only
Initial G0438, Subsequent G0439 over 65
EKG G0403, G0404, G0405
May at 9921-1 to 5 with modifer -25
