1. What are the potential ICD-10 codes in this case?
ICD-10 Code for non-insulin dependent diabetes mellitus without complications - E11.9
ICD-10 Code for new findings of SEM throughout precordium - R01.2
2. How can the NP determine if this patient is a new patient versus an established patient at the clinic?
Nurse Practitioner can determine the new patient with the established patient by using Evaluation and Management documentation guidelines. A new patient is new to the provider for the first time or has not been seen in the past 3 years. New patient should be reviewed with a detailed history, physical examination, and medical decision making. An established patient is the one who has already visited the physician and clinic previously and on follow-up visits.
3. What components of care will be used for reimbursement decisions for Mr. Jones?
History is the first key component used for reimbursement decisions. Physical examination, the medical decision about the management of the present problem and coordination of services are used for reimbursement services. NP should use CPT codes of a new patient for reimbursement.
4. What type of physical examination best fits what was performed on Mr. Jones?
Physical examination was done to focus on the problem, expanded problem, and detailed focus of patient condition. In this case, Mr. Jones examined for general health status, and body system was reviewed to identify the expanded problem of Mr.Jones.
5. If you were coding the visit for Mr. Jones, how would you determine what decision-making level you wot1ld choose? Provide your rationale and be specific
Medical decision will be taken under four categories such as straight forward, low complexity, moderate complexity, and high complexity. I will choose level 2 straight forward decision making for Mr.Jones because the major problem is uncontrolled blood sugar which leads to the associated problem. Otherwise, the Mr.Jones looks normal. If the blood sugar becomes controlled then he will have the only low risk of illness.
Robert Jones is a 45-year-old male who presents for diabetes He has been struggling with blood...
Case Study #9 Mr. Jones is a 45-year-old black male. He is 25 lbs overweight. He also has a family history of diabetes. His most recent lab work reveals an elevated fasting blood sugar, elevated total cholesterol, and low HDL level. 1. List Mr. Jones’ risk factors for type 2 diabetes 2. The physician sends Mr. Jones for nutritional counseling. What are your recommendations for him?
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