homeworkstudyhelp

Our Services

Get 15% Discount on your First Order

CASE 1 Please what is the right CPT and ICD-10 codes ? Write them…

CASE 1

Please what is the right CPT and ICD-10 codes ? Write them in the correct sequence.

The patient in Case 1-2 is the same patient in Case 1-1. The patient presents to the emergency department with nausea and recurrent vomiting.

1-2A EMERGENCY DEPARTMENT SERVICES LOCATION: Hospital Emergency Department

PATIENT: Sally Jacobson

PHYSICIAN: Paul Sutton, MD

CHIEF COMPLAINT: Nausea and recurrent vomiting with dehydration.

HISTORY OF PRESENT ILLNESS: The patient is a 17-year-old girl with type 1 diabetes mellitus since age 11 who has had pharyngitis for about the past 5 days. She was seen by her regular internist 2 days ago, and throat culture was negative.

The feeling was she had a viral pharyngitis because her brother had similar symptoms. The patient indicates that she has had nausea with some vomiting for the past 3 days and has really not eaten anything for the past 2 days. For the past day, she has had some diarrhea. She also indicates she has had some fever and chills and some cough. Generally, she feels poorly and indicates that she has been running to the bathroom quite frequently. She does indicate that she has taken all of her insulin shots as noted below, but she has not been able to eat. She does indicate that she has had an associated headache but no other symptoms. Blood sugar at noon today was about 190 mg% by Accu-Chek.

ALLERGIES: None known.

MEDICATIONS:
Ultralente 16 units, morning and evening.
Humalog 14 units in the morning, 7 units at noon, and 14 units at supper.
Albuterol nebulizer treatments p.r.n. (as needed).
PAST MEDICAL HISTORY: Asthma, presently albuterol p.r.n. Diabetes mellitus type 1 with several admissions for ketoacidosis.

PAST SURGICAL HISTORY: None.

FAMILY HISTORY: Positive in two brothers with type 1 dia- betes mellitus. She also has a cousin and uncle with diabetes. There is also positive family history for coronary artery disease. An uncle has lung cancer.

SOCIAL HISTORY: The patient is a senior in high school.

REVIEW OF SYSTEMS: Eyes: Blurred double vision. Ears: Hearing is okay. GI (gastrointestinal): As noted above. GU (genitourinary): As noted above. Cardiac: Negative. Chest: As noted above. She has had no SOB (shortness of breath) or heavy breathing. Hematologic: Negative. Infectious dis- ease: As noted above. Neurologic: Negative. Psychiatric: Negative. Sleep pattern has been off in the past, and she has been treated with amitriptyline. This has not been such a significant problem of late.

EXAMINATION: The patient appears dehydrated with sunken eyeballs and a flushed face. Blood pressure 102/70, pulse 120 and regular, and temperature 97.88 F. Tongue is mildly dry. Eyes: Good range of motion of the eyes, but the eyeballs are sunken. Neck: Supple. Nodes are negative. Ca- rotids are 4/4 without bruits. Thyroid is normal to palpa- tion. Chest: Clear to auscultation. Heart: Tachycardia is present, but no murmurs or extra sounds appreciated. No Kussmaul breathing is noted. Abdomen: Soft, nontender without palpable masses. Genitorectal: Not performed. Pe- ripheral extremities reveal good pulses and normal reflexes. No edema is present.

IMPRESSION:
Dehydration secondary to #2 with possible ketoacidosis.
Viral pharyngitis with what appears to be a gastroenteritis component.
Diabetes mellitus type 1, 6 years without complication.
Asthma, presently stable.
PLAN: The patient will be treated with intravenous fluids and insulin as indicated. Once she is able to eat and is ambulatory, she will be able to go home.

E/M service code: 99284
ICD-10-CM: E86.0, J02.9, E10.9, J45.909, R11.2

(The HPI included 6 elements: location (pharynx and stomach), severity (not eaten anything for the past 2 days),duration (5 days),timing (frequently [running to the bathroom]), modifying factors (taken all insulin shots), and associated signs and symptoms (fever, chills, cough, headache, blood sugar, unable to eat) for a level 4 or comprehensive HPI. The ROS included 10 elements: ophthalmologic (eyes),otolaryngologic (ears),cardiovascular, respiratory (no shortness of breath or heavy breathing), gastrointestinal, genitourinary, neurologic, psychiatric, hematologic, and immunologic (infectious disease) for a level 4 or comprehensive ROS. All 3 elements of the PFSH were noted for a level 4 or comprehensive PFSH. A comprehensive HPI (level 4), comprehensive ROS (level 4), and comprehensive PFSH (level 4) place this history service at a level 4 or comprehensive.
The examination included 4 constitutional elements of blood pressure, pulse, temperature,and general appearance (appears dehydrated with sunken eyeballs and a flushed face) for 1 organ system. There were 2 body areas of neck (supple) and abdomen (soft, nontender).There were 6 organ systems of ophthalmologic (eyes),otolaryngologic (tongue), respiratory (clear to auscultation), cardiovascular (heart, good pulses), lymphatic (neck nodes),and neurologic (normal reflexes).Note that although the thyroid was examined,the endocrine system is not listed as an examination organ system. The endocrine system is listed as an element of the ROS in the history, but not in the examination portion of the service. The total number of BAs/OSs is 9, which would ordinarily make this a level 4 or comprehensive examination; however, only OSs are counted for the comprehensive level. With a total of 7 OSs, this examination is a level 3 or detailed physical examination.
The MDM contained extensive diagnosis/management options (Type 1 diabetes mellitus that is not controlled, worsening pharyngitis, the new problem of dehydration, stable asthma, and possible ketoacidosis), no data indicated as reviewed, and a high risk to the patient if the condition were left untreated (the diabetes mellitus with complications) for a level 4 or high MDM.
The level of risk is subjective,and some might assign a moderate level of risk rather than a high level of risk to the patient. If a moderate level of risk were assigned, the code would not change from 99284.
The diagnoses are listed in the order as stated on the report in the Impression section,which is dehydration, pharyngitis, diabetes mellitus, and asthma. According to outpatient coding guidelines, you cannot code suspected conditions as if they exist, so the ketoacidosis cannot be reported.You can report present symptoms of nausea and vomiting,as no clear diagnostic statement has been made about the cause of the nausea and vomiting.)

 

Case 2 

This established ______ female patient comes complaining of severe pain on the right side of her face by her jaw. It began about 2 days ago, was a dull pain but now face is visible swollen. Fever, chills and unilateral pain and swelling developed quickly. The gland is firm and diffusely tender, with erythema and edema of the over lying skin. Pus can be expressed from the duct by compressing the affected gland and was cultured.  

Examination shows large swelling at the corner of the jaw; enlarged lymph nodes in the nek, and very tender to touch. Painful to open mouth but no inflammation in tonsils and adenoids. Mouth appears to be dry and limited saliva. The gland is firm and diffusely tender, with erythema and edema of the overlying skin. Pus was expressed from the duct by compressing the affected gland and sent for culture. 

Assessment: Acute sialadenitis. Begin antibiotics active against 5. aureus dicloxacillin, 250 mg po qid, modified according to culture results. Chlorhexidine 0.12% mouth rinses three times a day to reduce bacterial burned in the oral cavity and promote oral hygiene. Local measures including warm compresses, hydration, sialagogues ( eg, lemon juice, hard candy, or some other substance to trigger saliva flow), gland massage and good oral hygiene. 

Plan: Patient to being dicloxacillin immediately and oral rinses. To call if fever or pain increases. PTR in 3 days or sooner. Verify culture and change antibiotic as indicated  
 

WRITE the correct CPT and ICD codes and in the correct sequence.

 

 

 

 

 

 

 

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Cervical Spine additional views Swimmers Projection 1. What anatomy…

Cervical Spine additional viewsSwimmers Projection1. What anatomy do we visualise on a swimmer’s projection?2. What is the downside to using a swimmer’s projection?3. What is the result if the raised arm isn’t flat against the trolley?4. What is the centring point for the swimmer’s projection?C1/C2 open mouth projection1. What bony

Medication Name    Include BOTH Generic AND Trade names for RX;…

Medication Name    Include BOTH Generic AND Trade names for RX; include OTC, herbal (non-pharmacological items) Dose  Route Freq.   NOTE: PRN ‘alone’ ≠Freq Indications    (PRN meds must include MD ordered Indication) Mechanism of Action Side Effects/ Adverse Reactions Nursing Considerations specific to this patient with citations   What cues

1 .     What are the stages of human sexual response? What…

1.    What are the stages of human sexual response? What similarities and differences exist between the sexual response patterns of males and females? 2.      List 4 pattern of human sexual behavior.  3.      List the different types of relationships and lifestyles.   

1. What is the complete description of the abbreviation ICD-10-CM?…

1. What is the complete description of the abbreviation ICD-10-CM? (Hint: what does each part ofICD-10-CM refer to?)2. What is the complete description of the abbreviation ICD-10-PCS?3. What organizations have representatives that serve as members of the Cooperating Parties forICD-10-CM?4. What are the two parts of the Alphabetic Index?5. According

 how cardinality is applied to the databases you’ve been working…

 how cardinality is applied to the databases you’ve been working with and why different numbers of records returned from the different offices. Compare and contrast the different queries you ran and how cardinality applies to them. What are two of the crucial benefits of cardinality in this type of database.

Based on the data from the 2×2 table below and calculate the…

Based on the data from the 2×2 table below and calculate the cumulative incidence for each group then compute the following measures. Interpret each of these measures. (22 points)     Diseased Non-Diseased Total Exposed 6 9 15 Non-Exposed 2 13 15 Total 8 22 30   cumulative incidence of exposure

Loop diuretics and thiazide diuretics may cause an increase in…

Loop diuretics and thiazide diuretics may cause an increase in potassiumexcretion and hypokalemia in the serum because: A. Increased sodium delivered to the collecting ducts will result in the exchange of sodium for potassiumB. Diuretics will inhibit sodium and potassium reabsorption out of the lumen of the nephron.C. Potassium secretion

A 56-year-old female patient is admitted after being found…

A 56-year-old female patient is admitted after being found unresponsive at home. The patient had right-sided hemiplegia and aphasia from a previous CVA. The provider documents a current cerebral infarction due to occlusion of the right middle cerebral artery as the final diagnosis and the patient is transferred for rehabilitation.

1. What is the difference between a theory and a model? Provide an…

1. What is the difference between a theory and a model? Provide an example of each.    2. Identify and describe the basic premise of four community practice models. Then, select one of the models and articulate a scenario in which it could be appropriately applied.    3. What are

Review the sample research questions below and write a 1- to 2-page…

Review the sample research questions below and write a 1- to 2-page response that addresses the following: . Select one strong Research Question and one weak Research Question. .Explain the traits of the strong Research Question and the flaws of the weak Research Question.  .Refer to the resources to justify

In what ways could the positive effects of preventing malaria be…

In what ways could the positive effects of preventing malaria be offset by health problems caused by DDT? How does DDT spraying impact animal species, such as fish or birds of prey? If DDT spraying causes certain species to become extinct or endangered, what are some potential consequences for the

1. The elements of effective communication are:   a. Verbal,…

1. The elements of effective communication are:  a. Verbal, non-verbal communication and exchange of views  b. Transactional, sharing and processing. c. Be present at the time and make use and interpretation of verbal and non-verbal communication.  d. Verbal and non-verbal communication.   3. All of the following are factors affecting

the patient is a 25-year old, male brought to the emergency…

the patient is a 25-year old, male brought to the emergency department (ED) after being shot in the abdomen during a drive-by shooting. the patient was admitted to the hospital with the expectation he would be transferred to the surgical ICU after surgery. The trauma team assembled in the ED, and

The main theories of human behavior are systems theory,…

The main theories of human behavior are systems theory, behaviorism/social learning theory, psychodynamic theory, psychosocial development theory, transpersonal theory, social exchange theory, social constructivism, symbolic interactionism, conflict theory, and contingency theory. For this written assignment, in a three-page, paper, using a minimum of two sources, choose three theories of human

Vitamin/Mineral Supplement Comparison Purpose To compare the amount…

Vitamin/Mineral Supplement Comparison PurposeTo compare the amount of vitamins and minerals in a supplement to your own personal DRI/RDA recommendations. This activity will help you evaluate a good vs. potentially dangerous supplement. Here you will compare a supplement with your own personal DRIs to assess its benefits and risks.  Background

The HIPAA Privacy Rule has an exception that allows covered…

The HIPAA Privacy Rule has an exception that allows covered entities to disclose individuals’ protected health information (PHI) for purposes of treatment, payment, and health care operations (TPO). In an essay, one page in length (minimum): Explain the difference between the use and disclosure of PHI. Explain the activities allowed

In the early years of the 1960s, Civil Rights activists in…

In the early years of the 1960s, Civil Rights activists in Mississippi and Alabama played a crucial role in the Civil Rights movement. What were the key events of those first few years of the early 1960s? Who were the leaders of the movement? What did they accomplish and did