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. A.M. BS 200-300, P.M. BS 300-400. Did not go to diabetic education classes. “I could not fit them in to my busy schedule”. Past medical history: Back surgery for “protruding lumbar disc” 5 years ago. Depression Allergies: Codeine; rash Medications: Zoloft 100mg 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 attory for 15 years, works in sales. Nonsmoker No children <3 alcoholic drinks weekly. Review of Systems: General: Denies fever, weight loss, actually gained 10 lbs, night sweats Respiratory: Denies difficulties Cardiac No CP or palpitations Gastrointestinal: Appetite good, denies problems GU: Denies urinary frequency, no nocturia Musculoskeletal: Denies numbness, weakness, or sensation of pain in the upper extremities. Physical Examination: General: NAD. HT 5 '9”, WT 285 lb, BP 130/80, P-76, R-18. Cardiac RRR, S1,S2 no S3,S4, 3/6 SEM throughout precordium (new finding), Lungs CTA. Abd: soft, +BS no HSM, extremities no edema noted 1. What are the potential ICD-10 codes in this case? 2. How can the NP determine if this patient is a new patient versus an established patient at the clinic? 3. What components of care will be used for reimbursement decisions for Mr. Jones. 4. What type of physical examination best fits what was performed on 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

Answer 1

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.