Medical Coding -Need answer ASAP Cassidy presents to the Collegetown Clinic toda
ID: 74248 • Letter: M
Question
Medical Coding -Need answer ASAP
Cassidy presents to the Collegetown Clinic today for evaluation of throat pain and productive cough.
29-year-old woman is a new patient presenting with worsening daytime cough. Over the past three weeks, cough has become more persistent and hoarse, but cough does not interrupt sleep. Throat burns constantly during day. No identified postnasal drip, although patient rates throat pain at 8/10 all the time. Both cough and pain are much worse after eating evening meal. Identifies pain along the length of throat, a burning in her chest, and reports that her mouth tastes sour along with the presence of excessive saliva in her mouth. Throat lozenges exacerbate the pain but alleviate the bitter taste in her mouth. Ice chips provide temporary relief for pain. Patient feels very anxious about pain, reporting heart palpitations and anxiety: father diagnosed with stage II squamous cell esophageal carcinoma 14 months ago. Patient engaged in smoking cessation program nine months ago after a 12-year smoking habit. In addition to HPI, patient reports loss of appetite. No report of nausea, fever chills, diarrhea, swollen joints, unusual muscle aches, headache, double vision, painful urination, or shortness of breath. No identified skin rash. History of peptic ulcer at age 14, responded well to OTC treatment with no recurrence. Occasional problem with heartburn, but patient admits she has not kept track of her own health due to schoolwork, job and father’s health problems. Bronchitis complicated by pleurisy last year, responded well to ABX treatment. No history of asthma. No known drug allergies. 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, with flushed face but in no acute distress. Eyes clear without jaundice, EOMI intact, PERRLA. Oral examination reveals sour odor and copious amounts of salivation present along gum line and beneath tongue. Otherwise, oral mucosa intact. Oropharynx red but no inflammation or exudates noted along tonsils or adenoids. Neck soft without masses and non-tender, although patient reports radiating pressure when upon palpation of submaxillary lymph glands with significant pain upon swallowing during exam. Lungs clear to auscultation and percussion. Abdomen soft, non-tender upon palpation. Normal bowel sounds present. Patient alert, oriented times three. Cranial nerves intact.
Impression: 29-year-old woman with possible extra-esophageal manifestation of GERD.
Plan: Chest X-ray ordered to rule out lung congestion or esophageal mass. Upon review of X-ray, consider OTCproton pump inhibitor therapy and change of lifestyle to reduce stress and improve digestion, including eating five small meals throughout day and no food or drink more than 3 hours before bedtime.
Follow up in one week to review patient’s response to OTC pump inhibitor 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 the level 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: ____________________________________________________
Explanation / Answer
1) Is this a new patient or established patient- New Patient
2) Level of OVERALL history--- Level 2
a)Supported by HPI level:-- Expanded Problem Focused Exam
b) ROS level- 1 or more organ system
c) PFSH - 1pertinent PFSH
3)Ans: second lowest level of physical exam
4)Ans: Low complexity
a) problem point 2
b)data point 2
c) Low
5)Acute care
6) change of lifestyle to reduce stress .
Rational : Follow up in one week to review patient’s response to OTC pump inhibitor therapy and lifestyle changes.
7) E/M Service code : 99202