Robert Jones is a 45-year-old male who presents for diabetes. He has been strugg

Question

Robert Jones is a 45-year-old male who presents for diabetes. He has been struggling with blood sugar control. He travels for his job and eats out most days. He walks or goes to the gym when he can at least once a week. Takes metformin but forgets to take the second dose. AM BS 200-300, PM BS 300-400. Did not go to diabetic education classes. "1 could not fit them in to my busy schedule." Past Medical History Back surgery for "protruding lumbar disc 5 years ago Allergies Codeine; rash Zoloft 100 mg QD Metformin BID Family History: Osteoarthritis, DM, HTN: mother 75 y.o. Cerebral vascular accident; father deceased age 60 y.o. Social History Happily married to an attorney for 15 years, works in sales No children

Explanation / Answer

1,potential ICD-10 codes
Diabetes(type 2) E11
precordial friction R01.2
2, New patient visits can be differentiate from established patient with different categories
Evaluation and management(E/M) services can be applied for both new and established patient in office or other outpatient services and preventive medicine services..new patient is the one who will not received any professional services from same physician in same speciality who belongs to the same group practice within the past three years..
Established patient is one who already received services from same physician in same speciality within past three years..
New patient E/M services obtain patient history,cheif complaint,history of present illness,review of system.
3, CPT clarifies the conditions when a patient identified as new Vs established,except insurance providers,including medicare,they have policies to acknowledge a new patient..
4, physical exam for E/M documentation come under categories with problem focused,expanded problem focused ,detailed comprehensive.
Mr.jones physical examination come under expanded problem focused exam..because it includes vital signs,general apperance,auscultation of lungs and heart,examination of the abdomen,extremities for edema..
5, straight forward decison-making level will be choosen..because preventing problem are of low to moderate severity..patient chief complaint is diabetes.he is having all associated problem due to uncontrolled sugar..Other than that his body system looks normal with all examination..

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