Medical Coding -Need answer ASAP
Cassidy presents to the Collegetown Clinic today for evaluationof throat pain and productive cough.
29-year-old woman is a new patient presenting with worseningdaytime cough. Over the past three weeks, cough has become morepersistent and hoarse, but cough does not interrupt sleep. Throatburns constantly during day. No identified postnasal drip, althoughpatient rates throat pain at 8/10 all the time. Both cough and painare much worse after eating evening meal. Identifies pain along thelength of throat, a burning in her chest, and reports that hermouth tastes sour along with the presence of excessive saliva inher mouth. Throat lozenges exacerbate the pain but alleviate thebitter taste in her mouth. Ice chips provide temporary relief forpain. Patient feels very anxious about pain, reporting heartpalpitations and anxiety: father diagnosed with stage II squamouscell esophageal carcinoma 14 months ago. Patient engaged in smokingcessation program nine months ago after a 12-year smoking habit. Inaddition to HPI, patient reports loss of appetite. No report ofnausea, fever chills, diarrhea, swollen joints, unusual muscleaches, headache, double vision, painful urination, or shortness ofbreath. No identified skin rash. History of peptic ulcer at age 14,responded well to OTC treatment with no recurrence. Occasionalproblem with heartburn, but patient admits she has not kept trackof her own health due to schoolwork, job and fatherâs healthproblems. Bronchitis complicated by pleurisy last year, respondedwell to ABX treatment. No history of asthma. No known drugallergies. Patient is second year law student at Collegetown Law.Alcohol: two to four beers a week average.
Exam:
PE: 98.2 HR 28, RR 16, BP 115/71
Patient alert and well groomed, but clearly agitated, withflushed face but in no acute distress. Eyes clear without jaundice,EOMI intact, PERRLA. Oral examination reveals sour odor and copiousamounts of salivation present along gum line and beneath tongue.Otherwise, oral mucosa intact. Oropharynx red but no inflammationor exudates noted along tonsils or adenoids. Neck soft withoutmasses and non-tender, although patient reports radiating pressurewhen upon palpation of submaxillary lymph glands with significantpain upon swallowing during exam. Lungs clear to auscultation andpercussion. Abdomen soft, non-tender upon palpation. Normal bowelsounds present. Patient alert, oriented times three. Cranial nervesintact.
Impression: 29-year-old woman with possible extra-esophagealmanifestation of GERD.
Plan: Chest X-ray ordered to rule out lung congestion oresophageal mass. Upon review of X-ray, consider OTCproton pumpinhibitor therapy and change of lifestyle to reduce stress andimprove digestion, including eating five small meals throughout dayand no food or drink more than 3 hours before bedtime.
Follow up in one week to review patientâs response to OTC pumpinhibitor therapy and lifestyle changes.
1. Is this a new patient or established patient?______________________________
2. Level of OVERALL history?_________________________________________
a. Supported by HPI level:_______________________________________
b. ROS level:__________________________________________________
c. PFSH:_____________________________________________________
3. Using the 1997 General Exam (chapter 7) what would be thelevel of the physical examination:________________________________________________________
4. Overall level of medical decision-making complexity:_____________________
Supported by the following levels:
a. Number of diagnoses and/or management options (level):________________
b. Amount and/or complexity of data to be reviewed (level):_________________
c. Risk of complication, comorbidity, and/or mortality (level):_______________
5. Category: ________________
6. Subcategory: _______________________
Rationale:___________________________________________________________
7. E/M service code:____________________________________________________
Medical Coding -Need answer ASAP
Cassidy presents to the Collegetown Clinic today for evaluationof throat pain and productive cough.
29-year-old woman is a new patient presenting with worseningdaytime cough. Over the past three weeks, cough has become morepersistent and hoarse, but cough does not interrupt sleep. Throatburns constantly during day. No identified postnasal drip, althoughpatient rates throat pain at 8/10 all the time. Both cough and painare much worse after eating evening meal. Identifies pain along thelength of throat, a burning in her chest, and reports that hermouth tastes sour along with the presence of excessive saliva inher mouth. Throat lozenges exacerbate the pain but alleviate thebitter taste in her mouth. Ice chips provide temporary relief forpain. Patient feels very anxious about pain, reporting heartpalpitations and anxiety: father diagnosed with stage II squamouscell esophageal carcinoma 14 months ago. Patient engaged in smokingcessation program nine months ago after a 12-year smoking habit. Inaddition to HPI, patient reports loss of appetite. No report ofnausea, fever chills, diarrhea, swollen joints, unusual muscleaches, headache, double vision, painful urination, or shortness ofbreath. No identified skin rash. History of peptic ulcer at age 14,responded well to OTC treatment with no recurrence. Occasionalproblem with heartburn, but patient admits she has not kept trackof her own health due to schoolwork, job and fatherâs healthproblems. Bronchitis complicated by pleurisy last year, respondedwell to ABX treatment. No history of asthma. No known drugallergies. Patient is second year law student at Collegetown Law.Alcohol: two to four beers a week average.
Exam:
PE: 98.2 HR 28, RR 16, BP 115/71
Patient alert and well groomed, but clearly agitated, withflushed face but in no acute distress. Eyes clear without jaundice,EOMI intact, PERRLA. Oral examination reveals sour odor and copiousamounts of salivation present along gum line and beneath tongue.Otherwise, oral mucosa intact. Oropharynx red but no inflammationor exudates noted along tonsils or adenoids. Neck soft withoutmasses and non-tender, although patient reports radiating pressurewhen upon palpation of submaxillary lymph glands with significantpain upon swallowing during exam. Lungs clear to auscultation andpercussion. Abdomen soft, non-tender upon palpation. Normal bowelsounds present. Patient alert, oriented times three. Cranial nervesintact.
Impression: 29-year-old woman with possible extra-esophagealmanifestation of GERD.
Plan: Chest X-ray ordered to rule out lung congestion oresophageal mass. Upon review of X-ray, consider OTCproton pumpinhibitor therapy and change of lifestyle to reduce stress andimprove digestion, including eating five small meals throughout dayand no food or drink more than 3 hours before bedtime.
Follow up in one week to review patientâs response to OTC pumpinhibitor therapy and lifestyle changes.
1. Is this a new patient or established patient?______________________________
2. Level of OVERALL history?_________________________________________
a. Supported by HPI level:_______________________________________
b. ROS level:__________________________________________________
c. PFSH:_____________________________________________________
3. Using the 1997 General Exam (chapter 7) what would be thelevel of the physical examination:________________________________________________________
4. Overall level of medical decision-making complexity:_____________________
Supported by the following levels:
a. Number of diagnoses and/or management options (level):________________
b. Amount and/or complexity of data to be reviewed (level):_________________
c. Risk of complication, comorbidity, and/or mortality (level):_______________
5. Category: ________________
6. Subcategory: _______________________
Rationale:___________________________________________________________
7. E/M service code:____________________________________________________
Unlock all answers
