NU673-7D Unit 7 Discussion – CPT E&M Code and ICD-10 Diagnosis Code Herzing
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NU673-7D Unit 7 Discussion – CPT E&M Code and ICD-10
Diagnosis Code Herzing
Discussion Prompt
Use your
lecture materials to determine what CPT E&M Code and ICD-10 diagnosis code
to utilize for this ‘new patient’ encounter using the medical decision-making
(complexity) approach.
Provide
justification for the code you assigned by including the following information
in your discussion:
Case:
This patient
presents to a local health center. As the provider, you must conduct a
full physical on the patient as well as a psychiatric intake.
Liam is a
22-year-old who reports to you that he feels depressed and is experiencing
a significant amount of stress about school, noting that he’ll “probably flunk
out.” He spends much of his day in his dorm room playing video games and has a
hard time identifying what, if anything, is enjoyable in a typical day. He
states once he leaves the room he begins sweating and feels as if he has heart
palpations. He rarely attends class and has avoided reaching out to his
professors to try to salvage his grades this semester. Liam has
always been a self-described shy person and has had a very small and cohesive
group of friends from elementary through high school. Notably, his level of
stress significantly amplified when he began college. You learn that when
meeting new people, he has a hard time concentrating on the interaction because
he is busy worrying about what they will think of him – he assumes they will
find him “dumb,” “boring,” or a “loser.” When he loses his concentration, he
stutters, is at a loss for words, and starts to sweat, which only serves to
make him feel more uneasy. After the interaction, he replays the conversation
over and over again, focusing on the “stupid” things he said. Similarly, he has
a long-standing history of being uncomfortable with authority figures and
has had a hard time raising his hand in class and approaching teachers. Since
starting college, he has been isolating more, turning down invitations from his
roommate to go eat or hang out, ignoring his cell phone when it rings, and
habitually skipping class. His concerns about how others view him are what
drive him to engage in these avoidance behaviors. After conducting your
assessment, you give the patient feedback that you believe he has social
anxiety disorder, which should be the primary treatment target. You explain that
you see his fear of negative evaluation, and his thoughts and behaviors
surrounding social situations, as driving his increasing sense of hopelessness,
isolation, and worthlessness.
Significant
Symptoms:
- Anxiety
- Depression
- Ruminations
- Social Anxiety
- Physical symptoms; sweating, heart palpations
Vitals:
127/80
98
18
60
90%
BMI 30
225 lbs
72”
Physical
exam:
General: Well appearing,
well-nourished, in no distress. Oriented x 3, normal mood
and affect. Ambulating without difficulty.
Skin: Good
turgor, no rash, unusual bruising, or prominent lesions
Hair: Normal
texture and distribution.
Nails: Normal
color, no deformities
HEENT: Head:
Normocephalic, atraumatic, no visible or palpable masses, depressions, or
scaring. Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM
intact, PERRL, fundi have normal optic discs and vessels, no exudates or
hemorrhages
Ears: EACs
clear, TMs translucent & mobile, ossicles nl appearance, hearing
intact.
Nose: No
external lesions, mucosa non-inflamed, septum,
and turbinates normal
Mouth: Mucous
membranes moist, no mucosal lesions.
Teeth/Gums: No
obvious caries or periodontal disease. No gingival inflammation or significant
resorption. Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or
exudate
Neck: Supple,
without lesions, bruits, or adenopathy, thyroid non-enlarged and
non-tender
Heart: No
cardiomegaly or thrills; regular rate and rhythm, no murmur or
gallop
Lungs: Clear
to auscultation and percussion
Abdomen: Bowel
sounds normal, no tenderness, organomegaly, masses, or hernia
Back: Spine
normal without deformity or tenderness, no CVA tenderness
Rectal: Normal
sphincter tone, no hemorrhoids or masses palpable
Extremities:
No amputations or deformities, cyanosis, edema or varicosities, peripheral
pulses intact
Musculoskeletal:
Normal gait and station. No misalignment, asymmetry, crepitation, defects,
tenderness, masses, effusions, decreased range of motion, instability, atrophy
or abnormal strength or tone in the head, neck, spine, ribs, pelvis or
extremities.
Neurologic: CN
2-12 normal. Sensation to pain, touch, and proprioception normal. DTRs normal
in upper and lower extremities. No pathologic reflexes.
Psychiatric:
Oriented X3, intact recent and remote memory, judgment and insight, anxious
mood and affect.
Breast: No
nipple abnormality, dominant masses, tenderness to palpation, axillary or
supraclavicular adenopathy.
G/U: Penis
circumcised without lesions, urethral meatus normal location without discharge,
testes and epididymides normal size without masses, scrotum without
lesions.
- The level of medical complexity encompassed by including the
number of points for the diagnoses/management options and the
amount/complexity of data reviewed; then identify the level of risk for
complications, morbidity, mortality
- In the discussion explore how the ICD-10 Codes that
you assigned impact third-party payor reimbursement for this visit.
Responses need to address all components of the question, demonstrate
critical thinking and analysis and include peer-reviewed journal evidence to
support the student’s position.
Please be sure to validate your opinions and ideas with in-text
citations and corresponding references in APA format.
Please review the rubric to ensure that your response meets the
criteria.
Estimated time to complete: 2 hours
Discussion Peer/Participation Prompt
Please respond to at least 2 of your peer’s posts with substantive
comments using the following steps:
- Substantive comments add to the discussion and provide your fellow
students with information that will enhance the learning environment.
- References and citations should conform to APA standards.
- Remember: Please respect the opinions of others, even if their
views differ. In other words, disagree professionally and respectfully.
- Plagiarism is never acceptable – give credit when
credit is due – cite your sources.
Responses need to address all components of the question, demonstrate
critical thinking and analysis, and include peer-reviewed journal evidence to
support the student’s position.
Please be sure to validate your opinions and ideas with in-text
citations and corresponding references in APA format.
Please review the rubric to ensure that your response meets the
criteria. Collaboration points will be forfeited if you fail to meet the
response post guidelines.
Estimated time to complete: 1 hour
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