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Garcili

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Hi wondering if this visit is billable   EM 99213 mod 24 

Pt is post op 11.1.17  she had a Transvaginal cervical Trachelectomy for abnormal pap smears high risk HPV and she had a prior supracervical hysterectomy.

on this visit 1.4.18  states bowels are continuing to improve she still experiences constipation  with suppository. she attempts to modified diet with water intake without significant improvement. Denies vag bleeding but has a moderate amount of vaginal discharge. she noticed occasionally urine smell to the discharge but does not experiencing incontinence.

assessment  s/p tvct  for abn pap . continued GI disturbance namely constipation, continued small vag discharge possible due to urinary incontinence.

Plan: Pelvic exam negative today will proceed with ua in the event she is experiencing incontinence that is otherwise asymptomatic to related urinary tract infection.Refer her to Nutrisionist . Will return to the office in 3 moth continued surveillance and pelvic examination. 

thank you for  your assistance.
Garcili
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