In the following questions, you will be asked to assign both the E/M code(s) and the diagnosis code(s).
Be sure and enter your answers with only a single space between each of the codes. DO NOT USE ANY PUNCTUATION. Format your answer with the E/M CPT code listed first, followed by the ICD-10 code(s). (E.G., 99214 A2.34 B3.45)
Do not worry about adding CPT modifiers or in-office procedure codes.
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An 18-year-old patient presented to the primary care physician’s office and reported experiencing a dry cough, low-grade fever (100.5°F), and shortness of breath for the past five days. The symptoms were progressively worsening, and the patient had a known exposure to a COVID-19-positive individual. The physician conducted a comprehensive evaluation and diagnosed the patient with COVID-19 and acute bronchitis. Assign both the E/M and ICD-10 codes.
A 49-year-old patient presented to the primary care physician’s office and reported having a painful and progressively enlarging abscess on her left upper arm. The abscess was associated with redness, swelling, and tenderness. Additionally, the patient had a fever for the past five days. The physician conducted a comprehensive evaluation, diagnosed the patient with an abscess. The physician performed an incision and drainage procedure to evacuate the abscess and alleviate symptoms. A culture was performed, which revealed the growth of Staphylococcus. A prescription for oral antibiotics was provided. The patient received instructions on wound care, including the use of warm compresses and proper hygiene. The patient was scheduled for a follow-up visit in two days to assess the response to treatment, monitor wound healing, and evaluate the need for any further intervention. Assign both the E/M and ICD-10 codes.
A 68-year-old female patient presented to the primary care physician’s office with symptoms including fever, hypotension, and altered mental status. The physician conducted a comprehensive evaluation. The patient was diagnosed with sepsis due to Klebsiella pneumonia, with evidence of acute respiratory failure. Intravenous broad-spectrum antibiotics targeting Klebsiella pneumonia were initiated. The patient was admitted to the hospital for further monitoring, management of sepsis, and respiratory support if necessary. Assign both the E/M and ICD-10 codes.
A 45-year-old male, presents to the office with complaints of facial pain, difficulty in swallowing, generalized weakness, and tingling sensation in his hands and feet. The physician conducted a comprehensive evaluation, and the patient was diagnosed with mumps complicated by polyneuropathy. Physician ordered bilateral upper and lower extremity nerve conduction studies to assess the extent and severity of the polyneuropathy. Scheduled an MRI to evaluate for any structural abnormalities or compression contributing to the facial pain and associated symptoms. Prescribed over-the-counter pain relievers for facial pain management. Prescribed medication for neuropathic pain to alleviate tingling sensation and discomfort in the extremities. Emphasized the importance of hydration and maintaining a well-balanced diet to support recovery and overall well-being. Patient is to schedule a follow-up appointment in one week to review the results of the nerve conduction studies and MRI, adjust the treatment plan as necessary, and monitor progress. Assign both the E/M and ICD-10 codes.
A 25-year-old patient recently returned from a trip overseas and is presenting with symptoms of vomiting, diarrhea, and fever. These symptoms started approximately one week after her return. The physician performed a comprehensive examination and a lab test revealed that she has Hepatitis E. Instructed the patient to get plenty of rest. Advised maintaining good hydration by drinking fluids such as water, clear broths, and electrolyte-rich beverages. Scheduled a follow-up appointment in two weeks to assess the patient’s recovery, review symptoms, and address any concerns. Assign both the E/M and ICD-10 codes.
A 56-year-old male presents today for a routine office visit as part of the evaluation process for a liver transplant. The patient has a history of chronic hepatitis C infection, which has resulted in the need for a liver transplant. The physician performs a comprehensive evaluation. Assessment: 1. Chronic Hepatitis C 2. Waiting for liver transplant. Plan: adjust medications to alleviate symptoms such as fatigue, jaundice, abdominal pain, and weight loss. Optimize diuretic therapy. Monitor and manage nutritional status and provide dietary guidance to support overall health. Assign both the E/M and ICD-10 codes.
A 52-year-old male with a known HIV infection presents to the clinic. He has a history of HIV-related pneumonia but currently denies any active problems or symptoms. The physician performs a complete examination. Assessment: 1. Well-controlled HIV infection on antiretroviral therapy. 2. No active problems or symptoms reported at this time. 3. History of HIV-related pneumonia, resolved without complications. Plan: Continue current antiretroviral therapy. Schedule regular follow-up visits every 3 weeks to monitor HIV management, assess treatment response, and address any concerns. Reinforce the importance of medication adherence and consistent condom use. Provide education on maintaining a healthy lifestyle, including regular exercise, a balanced diet, and avoidance of tobacco and excessive alcohol consumption. Offer appropriate counseling and resources for support, including mental health services and HIV support groups. Discuss the importance of routine vaccinations, including annual influenza vaccine and pneumococcal vaccination. Assign both the E/M and ICD-10 codes.
Johnson, a 19-year-old female, presents today for the removal of genital warts. She reports noticing the warts approximately three weeks ago and is concerned about their appearance and potential transmission. Visual examination reveals multiple raised, flesh-colored papules in the genital area consistent with genital warts. No other concerning findings noted. Cryotherapy procedure performed. Scheduled a follow-up appointment in four weeks to assess treatment response, monitor for any recurrent warts, and address any concerns or questions. Assign both the E/M and ICD-10 codes.
Smith, a 16-year-old female, presents today with complaints of vaginal itching and increased vaginal discharge. The physician performed a complete examination. Lab tests documented: Positive for Chlamydial Vaginosis. Antibiotics prescribed and follow up in four weeks is scheduled. Assign both the E/M and ICD-10 codes.