Question

Module 6 Teena Kissee Case Study I What are the potential ICD-10 codes in this case? 1. a. 2. How can the NP determine if the patient v/s an established patient at the clinic? 3. What components of care will be used for reimbursement decisions for Ms. Ward? 4. What type of physical examination level best fits what was performed on Ms. Ward? 5. If you were coding the list for Ms. Ward, how would you determine what decision-making level you would choose? Provide rationale and be specific

Answer 1

1. In the present scenario. Ms Ward is a 19year old female with chief complaints of a 2-day history of burning with urination and vaginal discharge with a foul smell. And as well as in the wet mount she is positive for Whiff and clue cells, that may indicate the patient is suffering from bacterial vaginosis.

Thus we can apply the ICD-10 CM code for the present scenario is  N76.0

2. An individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face services (e.g., surgical procedure) from the same physician or physician group practice (same physician speciality and subspecialty) within the previous 3 years is called a new patient.

Individual who has received any professional services, E/M service or other face-to-face services (e.g., surgical procedure) from this provider or another provider (same speciality or subspecialty) in the same group practice within the previous three years. is considered as an established patient.

He from the past history the NP came to the conclusion that she is a new patient.

3. Medically necessary doctors services, preventative care, lab tests, x-rays will be used for reimbursement decisions for Ms Ward

4. In the physical examination possibly no symptoms.

For the vaginitis mainly we are using the inspection for fishy-smelling vaginal discharge,

5. When deciding a medical visit to Ms Ward we can give the education to prevent the complications. include avoiding feminine hygiene sprays and scented tampons; do not douche, and instead let your genitalia naturally cleanse itself; do not use soap or detergent to clean the vulva as these upset the normal balance of organisms.