What is the professiona code and cpt icd-10-cm codes for this case? Reason for Visit: General history and physical, yearly exam, seen a year ago by me. HPI: Harry is here today for a general history and physical. He reports that he is currently feeling well and has no major concerns today. Chronic Medical Problems: Positive history of hypertension. Currently takes hydrochlorothiazide 25 mg 1 by mouth daily for this. He reports no headache, no visual changes, no chest pain, and no shortness of breath. Also has a positive history of dyslipidemia and he currently takes Vytorin for this. Again, he reports no myalgias, arthralgias, chest pain or shortness of breath with this medication. Past Medical History: Reveals no significant hospitalizations or injuries. He has a positive history of congenital nystagmus. Positive history of mild gastroesophageal reflux disease which has resolved well intermittently with over the counter medications. Past Surgical History: Reveals only a vasectomy. Allergies and Alerts: Drug allergies/adverse reactions: Salicylates: hives No known non drug allergies/adverse reactions (NKNDA) No known drug allergies Medications: Vytorin10/40 Hydrochlorothiazide 25 mg Ranitidine HCI 75 mg tablet, 1 or 2 by mouth once daily as needed Family History: Reveals there is no family history of diabetes mellitus, prostate or colon cancer. There is a positive family history of heart disease in paternal grandfather at age 48. There is a positive family history of carotid artery disease in his paternal grandfather as well as uncle and father. They have all been in their 70s. There is a positive family history of hypertension in the maternal grandmother at age 44 and a stroke in her at the same time. Social History: He is married. He and his wife have 3 children. He works in construction. He drinks 4-5 cups of coffee a day. He drinks 1-2 cans of beer daily. He is a prior smoker who quit several years ago. Review of Systems: A 10 point review of systems is entirely negative with the exception of some insomnia and intermittent heartburn from fatty foods.
Screening History: Reveals last colonoscopy was done 4/1/05 and
was negative. Recommendation for follow up screening colonoscopy in
10 years. Last prostate cancer testing was in January 2007. This
was normal.
Vitals:
Respiration: 16rpm, BP 128/80 mm Hg (right, sitting; standard
cuff), Pulse: 72 bpm, temp: 36.3 C (tympanic), BMI: 30.4 kg/m^2,
ht: 184.15cm, wt: 103.0 kg (227 lb)
Examination: General: awake, alert and in no acute distress, HEENT:
Ears: TMs with appropriate bony landmarks bilaterally. Eyes: PERRL,
EOMI, fundoscopic exam reveals sharp discs without hemorrhages or
exudates. Sclerae are nonicteric. Nares: Patent without erythema or
swelling. Oropharynx: No erythema or exudates. No oral lesions.
Neck: No lymphadenopathy or thyromegaly. Trachea is midline.
Carotid pulses 2/4 bilaterally with no bruits. Chest: Clear to
auscultation with unlabored breathing. Cardiovascular: Normal S1
and S2 without S3, S4, or murmur. Abdomen: Positive bowel sounds,
soft, nontender without masses or hepatosplenomegaly.
Genitourinary: Reveals testes to be descended. Prostate: Reveals
prostate to be small, firm, flat without lumps or masses. There is
no tenderness. Extremities: No cyanosis, clubbing or edema. Pedal
pulses are 2/4 and symmetric of the dorsalis pedis and posterior
tibialis pulses bilaterally. Neurologic: Cranial nerves 2-12 are
intact to formal testing. No resting tremor. The patient also has
intact Achilles and knee reflexes bilaterally, both being 2/4 and
symmetric. Musculoskeletal: Reveals appropriate strength in the
major muscle groups of the upper and lower extremities to formal
testing. Skin: Reveals no concerning lesions.
Data: FLP, Chem 12, CBC and urinalysis are going to be requested
today for patient’s follow up of his hypertension and dyslipidemia.
PSA for prostate screening is requested today.
Assessment:
1. Health maintenance, adult
2. Hypertension
3. Dyslipidemia
4. Diabetes screening
5. Prostate screening.
Plan:
Regarding health maintenance: Anticipatory guidance pertinent to 53
year old is reviewed today. He is up to date on colon cancer
screening. Prostate screening done today and is normal. Diabetes
screening is going to be done today. He is encouraged to continue
with excellent health habits.
Hypertension: His blood pressure goal is less than 140/80. He is
currently at that goal. His current medications will be
continued.
Evaluation and
A code of professional conduct is a necessary component to any profession to maintain standards for the individuals within that profession to adhere. It brings about accountability, responsibility and trust to the individuals that the profession serves.
ICD -10-CM code is the tenth version of international classification of disease and is used by the healthcare workers to code a disease and is also used by the insurance company's for reimbursement purpose.
ICD -10-CM code for :-
- Hypertension is I10
- Dyslipidemia is E78.5
- Congenital nystagmus is H55.01
- Mild gastroesophageal reflux is K21.9
CPT code is the current procedural terminology used by the healthcare workers to code a procedure and is also used by the insurance company's for reimbursement purpose.
- Diabetes screening is 82947
- Prostate screening is 84153
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