medical coding and billing

LOCATION: Outpatient, clinic
PATIENT: Andrew Vetter
PRIMARY CARE PHYSICIAN: Alma Naraquist, MD
CHIEF COMPLAINT: Recheck diabetes.
He has started doing PT to get his strength back and has noted improvement. He has not been having any chest pain or
SOB.Past history of CAD.
His DM has been variably controlled. He is taking Lantus 28 units in the evening and Humalog 12 units with meals. He is
testing 2-4 times per day. He is having reactions around 3PM about once a week. He does get a warning with the reactions.
His sugars are highly variable at all testing times with high and low sugars. His evening sugars tend to be high, and he may
overeat after supper.
He continues to have numbness in the feet. There is no edema. His depression seems to be ok.
EXAM: Vitals: Weight is 180. Blood Pressure is 120-70. Patient is alert and conversant. He is near his ideal weight. There is
no edema. The foot pulses are normal. The ankle and knee reflexes are normal. There is a slight decrease in the vibratory
sensation. The chest is clear. Cardiac: The heart is regular with no murmur or S3. The abdomen is soft and nontender with no
masses. The rectum is normal, and there are some small hemorrhoids noted. The stool is hemoccult negative.
IMPRESSION: 1) DM Type I with variable control 2) Hemorrhoids 3) CAD, Stable
PLAN: Anusol suppository bid prn and tub soaks. He may need to cut the noon Humalog by 2 units. See in 4 months with a
HgbA1C.
Under what subheading in the Evaluation and Management services section of your CPT-4 manual will you locate the
appropriate code for these services?

re: medical coding and billing

If Andrew Vetter is the patient's real name, this is a HIPAA violation. I strongly suggest you redact any Protected Health Information prior to posting on a public forum. I would also suggest redacting the physician's name as well.

re: medical coding and billing

99214

re: medical coding and billing

Yes if this is the dr's name and patient delete immediately

re: medical coding and billing

It is scenario only. People are fictional...:>)

re: medical coding and billing

[LOCATION: Outpatient, clinic
PATIENT: Andrew Vetter
PRIMARY CARE PHYSICIAN: Alma Naraquist, MD
CHIEF COMPLAINT: Recheck diabetes.
He has started doing PT to get his strength back and has noted improvement. He has not been having any chest pain or
SOB.Past history of CAD.
His DM has been variably controlled. He is taking Lantus 28 units in the evening and Humalog 12 units with meals. He is
testing 2-4 times per day. He is having reactions around 3PM about once a week. He does get a warning with the reactions.
His sugars are highly variable at all testing times with high and low sugars. His evening sugars tend to be high, and he may
overeat after supper.
He continues to have numbness in the feet. There is no edema. His depression seems to be ok.
EXAM: Vitals: Weight is 180. Blood Pressure is 120-70. Patient is alert and conversant. He is near his ideal weight. There is
no edema. The foot pulses are normal. The ankle and knee reflexes are normal. There is a slight decrease in the vibratory
sensation. The chest is clear. Cardiac: The heart is regular with no murmur or S3. The abdomen is soft and nontender with no
masses. The rectum is normal, and there are some small hemorrhoids noted. The stool is hemoccult negative.
IMPRESSION: 1) DM Type I with variable control 2) Hemorrhoids 3) CAD, Stable
PLAN: Anusol suppository bid prn and tub soaks. He may need to cut the noon Humalog by 2 units. See in 4 months with a
HgbA1C.
identify the correct diagnosis (icd-9-cm) code(s) for the above scenario

re: medical coding and billing

[[LOCATION: Outpatient, clinic
PATIENT: Andrew Vetter
PRIMARY CARE PHYSICIAN: Alma Naraquist, MD
CHIEF COMPLAINT: Recheck diabetes.
He has started doing PT to get his strength back and has noted improvement. He has not been having any chest pain or
SOB.Past history of CAD.
His DM has been variably controlled. He is taking Lantus 28 units in the evening and Humalog 12 units with meals. He is
testing 2-4 times per day. He is having reactions around 3PM about once a week. He does get a warning with the reactions.
His sugars are highly variable at all testing times with high and low sugars. His evening sugars tend to be high, and he may
overeat after supper.
He continues to have numbness in the feet. There is no edema. His depression seems to be ok.
EXAM: Vitals: Weight is 180. Blood Pressure is 120-70. Patient is alert and conversant. He is near his ideal weight. There is
no edema. The foot pulses are normal. The ankle and knee reflexes are normal. There is a slight decrease in the vibratory
sensation. The chest is clear. Cardiac: The heart is regular with no murmur or S3. The abdomen is soft and nontender with no
masses. The rectum is normal, and there are some small hemorrhoids noted. The stool is hemoccult negative.
IMPRESSION: 1) DM Type I with variable control 2) Hemorrhoids 3) CAD, Stable
PLAN: Anusol suppository bid prn and tub soaks. He may need to cut the noon Humalog by 2 units. See in 4 months with a
HgbA1C.
identify the correct diagnosis (icd-9-cm) code(s) for the above scenario

]

re: medical coding and billing

[[LOCATION: Outpatient, clinic
PATIENT: Andrew Vetter
PRIMARY CARE PHYSICIAN: Alma Naraquist, MD
CHIEF COMPLAINT: Recheck diabetes.
He has started doing PT to get his strength back and has noted improvement. He has not been having any chest pain or
SOB.Past history of CAD.
His DM has been variably controlled. He is taking Lantus 28 units in the evening and Humalog 12 units with meals. He is
testing 2-4 times per day. He is having reactions around 3PM about once a week. He does get a warning with the reactions.
His sugars are highly variable at all testing times with high and low sugars. His evening sugars tend to be high, and he may
overeat after supper.
He continues to have numbness in the feet. There is no edema. His depression seems to be ok.
EXAM: Vitals: Weight is 180. Blood Pressure is 120-70. Patient is alert and conversant. He is near his ideal weight. There is
no edema. The foot pulses are normal. The ankle and knee reflexes are normal. There is a slight decrease in the vibratory
sensation. The chest is clear. Cardiac: The heart is regular with no murmur or S3. The abdomen is soft and nontender with no
masses. The rectum is normal, and there are some small hemorrhoids noted. The stool is hemoccult negative.
IMPRESSION: 1) DM Type I with variable control 2) Hemorrhoids 3) CAD, Stable
PLAN: Anusol suppository bid prn and tub soaks. He may need to cut the noon Humalog by 2 units. See in 4 months with a
HgbA1C.
identify the correct diagnosis (icd-9-cm) code(s) for the above scenario

]