NU673-7D Unit 7 Discussion – CPT E&M Code and ICD-10 Diagnosis Code Herzing

 NU673-7D Unit 7 Discussion – CPT E&M Code and ICD-10 Diagnosis Code Herzing

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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. 

1.        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 

2.       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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