1.INPATIENT HOSPITAL (MEDICARE) GENDER: Male AGE: 67 STATUS:…

Question Answered step-by-step 1.INPATIENT HOSPITAL (MEDICARE) GENDER: Male AGE: 67 STATUS:… 1.      INPATIENT HOSPITAL (MEDICARE)GENDER: MaleAGE: 67STATUS: Initial CHIEF COMPLAINT: LUQ pain and swelling, increasing over the past 3 days, indigestion. Pt is admitted.HISTORY: Comprehensive. Pain is worse after eating; does not smoke; weekly alcohol consumption at 2-3 cases of beer 10 years. EXAMINATION: A comprehensive GI exam; abdominal tenderness in the LUQ without masses; liver and spleen WNLMEDICAL DECISION MAKING: Moderate complexity with stool sample collected; abdominal US; IV fluids with pain control; GI consult orderedASSESSMENT: Acute pancreatitis, alcohol induced Tip: Refer to Medicare rules for billing this type of service.1 ICD-10-CM CODE:1 CPT CODE:2.      INPATIENT HOSPITALGENDER: FemaleAGE: 42 STATUS: Discharge REASON FOR ADMISSION: Patient found nonresponsive. Family reports patient being on a fast.COURSE OF TREATMENT: IV fluids increased to soft dietASSESSMENT: Nondiabetic hypoglycemic comaPLAN: Instructed on diet and glucometer, FU in 1 week TIME SPENT: 10 minutes1 ICD-10-CM CODE:1 CPT CODE:3.      OFFICEGENDER: Female AGE: 42STATUS: Established CHIEF COMPLAINT: Blood pressure check HISTORY: Long-time patient with hypertension, which has been difficult to control. Patient is here for her twice weekly BP check.EXAMINATION: Blood pressure check by the nurse. BP reading is 120/72 today.Tip: Minimal time is spent by the nurse under supervision of the physician for a routine office visit. 1 ICD-10-CM CODE:1 CPT CODE:4.      OFFICEGENDER: Male AGE: 52STATUS: NewCHIEF COMPLAINT: Dizziness upon standing, temporary visual dimming, numbness and tingling in arms and handsHISTORY: History of present illness, ROS, and PFSH reviewed in detailEXAMINATION: Detailed constitutional exam of vital signs and general appearance; detailed CV exam MEDICAL DECISION MAKING: BP to be checked daily and follow instructions related to lifestyle changes (i.e., improve diet and exercise); low complexity ASSESSMENT: Orthostatic hypotension Tip: Identify the setting and the type of service.1 ICD-10-CM CODE:1 CPT CODE:5.      INPATIENT HOSPITALGENDER: FemaleAGE: 71STATUS: NewCHIEF COMPLAINT: Patient referred by Dr. Conover for consult on peripheral autonomic neuropathyHISTORY: Comprehensive history. The patient also has type 2 diabetes, which has been well managed with diet and lifestyle. EXAMINATION: Comprehensive examination MEDICAL DECISION MAKING: High complexity. Rx and tests. Return in 6 weeks. Report sent to Dr. Conover. ASSESSMENT: Type 2 DM, peripheral neuropathy Tip: Determine whether the neuropathy is related to the diabetes. Refer to Medicare rules for billing this type of service.1 ICD-10-CM CODE:1 CPT CODE:6.      OFFICEGENDER: FemaleAGE: 4 STATUS: Established REASON FOR ENCOUNTER: Routine exam of a 4-year-oldHISTORY: Normal healthy female child; immunizations up to date; detailed history obtainedEXAMINATION: Detailed exam; no new findings PLAN: RTO in 1 year, call if any new problemsTip: Determine the type of service for this visit.1 ICD-10-CM CODE:1 CPT CODE:7.      EMERGENCY DEPTGENDER: MaleAGE: 24 STATUS: NewCHIEF COMPLAINT: In pain with swollen wrist, unable to bend HISTORY: Expanded problem focused. Patient slipped walking across an icy driveway and used his right hand to break his fall. EXAMINATION: Expanded problem focusedMEDICAL DECISION MAKING: Low. X-ray of the right arm reviewed.ASSESSMENT: Fracture of the distal right radius Tip: Injury codes should be followed by external cause codes. Sequence the external cause codes correctly.3 ICD-10-CM CODES:1 CPT CODES: 8.      NURSING FACILITYGENDER: FemaleAGE: 87STATUS: Established CHIEF COMPLAINT: Cellulitis, left leg HISTORY: Problem focused, cellulitis improved on IV antibiotic EXAMINATION: Problem-focused examination limited to left leg, less swellingMEDICAL DECISION MAKING: Discontinue IV antibiotic and start oral antibiotic; topical medication; DM and HTN stable 3 ICD-10-CM CODES:1 CPT CODE:9.      INPATIENT HOSPITALGENDER: MaleAGE: 77STATUS: Established CHIEF COMPLAINT: Acute renal failureTREATMENT: Reviewed lab results and renal ultrasound; discussed possible dialysis with patient and limitations due to anteroseptal MI last week; nephrologist consulted; central line discontinuedTIME SPENT: Critical care provided from 1700 to 18201 ICD-10-CM CODES:2 CPT CODE:10.  OFFICEGENDER: Male AGE: 59STATUS: New CHIEF COMPLAINT: Patient comes in today for a migraine, which started two days ago with auraHISTORY: Detailed; patient is referred by his PCP for neurological evaluation of pharmacoresistant migraine EXAMINATION: Detailed examination of multiple body areasMEDICAL DECISION MAKING: Low complexity, Rx for zolmitriptan and Cafergot ASSESSMENT: Migraine with aura 1 ICD-10-CM CODE:1 CPT CODE: Health Science Science Nursing CONSULT TE MOT 132 Share QuestionEmailCopy link Comments (0)

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