Preview

Hcr220 Week5

Satisfactory Essays
Open Document
Open Document
393 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Hcr220 Week5
HCR/220
October 30, 2011
Assignment: Assigning Evaluation and Management (E/M) Codes

#1. Initial consultation is performed for a 78-year-old woman with unexplained weight loss, abdominal pain, and rectal bleeding. A comprehensive history and examination is performed.
Code: 99205
Seeing as though this patient is 78 years old, we are assuming that we are billing Medicare for these procedures. I chose the code above due to the presentation of problems such as unexplained weight loss, abdominal pain and rectal bleeding because it is a high MDM and that this patient is considered high risk.

#2. A 30-year-old returning patient presents complaining of flu-like symptoms characterized by unremitting cough, sinus pain, and thick nasal discharge. An examination reveals bronchitis and sinus infection. The patient is prescribed a 5-day course of Zithromax.
Code: 99202
This is an office visit, new patient but the history of the same symptoms as prior office visit. The patient still has 2 or more conditions but the treatment is straight forward that is why we have to use 99202.

#3. Established patient on Lithium presents for routine blood work to monitor therapeutic levels and kidney function. A nurse reviews the results and advises the patient that tests are normal, and no change in dosage is indicated.
Code: 99211
This is an example of incident to service. The nurse is following the guidelines set forth by the physician.

#4. A 62-year-old established diabetic female presents for check-up and dressing change of wound on left foot. An examination reveals the wound is healing. The nurse applied new dressing and patient will return for a check-up in one week.
Code: 99212
I chose this code due to it being problem-focused but yet straightforward. Due to the patient having diabetes the risk was minimal and important for her wounds to heal on the feet of diabetic patients. If wounds are not treated, she can lose her foot.

#5. A mother brings in

You May Also Find These Documents Helpful

  • Satisfactory Essays

    0830 Focus assessment. Alert and oriented x 4 and follow commands. VS T 96.7, P 76, R 18, BP 129/67, O2 Sat 94 RA. Pt denied pain at this time. Pain 0 on a scale of 0 to 10 Heart sounds normal, regular and even. S1 and S2 auscultated. Lung sounds normal and clear in all lobes. Non labored and non-shallow. Bowel sounds active and present in all four quadrants. ABD soft, non-tender to palpate. Pt denied ABD pain and constipation. Pt stated last bowel movement two days ago (2/23). Call light with in her reach, all necessary items close by pt………………………..L.Gotora PNS2/WATC…

    • 210 Words
    • 1 Page
    Satisfactory Essays
  • Powerful Essays

    Case 8 H&P Gerald Edwards

    • 610 Words
    • 3 Pages

    HISTORY OF PRESENT ILLNESS: This is a 53-year-old black individual a patient of Dr. Shelton, who has had diabetes for at least six months, but he thinks it has been longer than that. He says his last known blood sugar was in the 300’s. He presents in the ER today with a foot ulcer since January of this year. He stated that it started with blisters where he had soaked his feet too long in hot water. He has had no eye examination for two years. There has been no surveillance of chronic complications of diabetes.…

    • 610 Words
    • 3 Pages
    Powerful Essays
  • Good Essays

    3. What is the priority nursing action to address Marie's needs related to the repair of her 4th degree perineal laceration?…

    • 348 Words
    • 2 Pages
    Good Essays
  • Satisfactory Essays

    Pathology Report

    • 1667 Words
    • 48 Pages

    GROSS DESCRIPTION: Exam of the specimen designated “left fallopian tube” reveals the presence of a fallopian tube measuring 6 cm in length and 2.3 cm in average diameter. Sectioning of the tube shows it to be distended with blood clot and possible fetal tissue. Repression sections are taken and placed in 3 cassettes, A through C for embedding.…

    • 1667 Words
    • 48 Pages
    Satisfactory Essays
  • Satisfactory Essays

    Wound Incident Analysis

    • 316 Words
    • 2 Pages

    While on the floor with the nurses, I saw how they do their skin assessments to check for pressure ulcers or any kind of skin breakdown. They looked at patient’s elbows, back and their heels and they documented their findings. While the nurse was documenting, she also let me see that if a patient’s Braden score is <18 that they would contact a nutritionist if the patient did not already have one.…

    • 316 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    Diabetes Case Studies

    • 608 Words
    • 3 Pages

    The patient once again, has not been taking care of himself. He states he has not been exercising like he knows he should, he is not eating well. He is not taking his medications as prescribed. He is only taking his metformin ER 500 mg two tablets with dinner four days per week instead of taking it two tablets twice a day, daily. He is also not taking his NovoLog sliding scale. He does tell me he takes his Lantus 50 units at night. He has been checking his blood sugars once a day, generally before lunch and they have ranged from 115 to 180, but does tell me he has had some outliers that have been higher than that. He has been trying to eat more consistently, trying to get a breakfast in, but eats cereal for breakfast.…

    • 608 Words
    • 3 Pages
    Good Essays
  • Satisfactory Essays

    I have received a patient complaint today while I was over at Digestive Health. MRN: 214785…

    • 239 Words
    • 1 Page
    Satisfactory Essays
  • Good Essays

    Diabetes mellitus is a global health problem that affects more than 387 million individuals which leads to multiple comorbidities and estimates a loss of $245 billion in medical cost and loss of wage (Tchanque-Fossuo, et al., 2016). One of the most common and serious complication of diabetes mellitus is diabetic foot ulcer. Approximately 15% percent of diabetic patients will develop a foot ulcer in their lifetime and 6-40% of diabetic patients must receive a limb amputation (Kajagar, Godhi, Pandit, & Khatri, 2012). Currently, diabetic foot ulcer accounts for more than 60% percent of non-traumatic lower limb amputation (Tchanque-Fossuo, et al., 2016).…

    • 1372 Words
    • 6 Pages
    Good Essays
  • Powerful Essays

    Reflection-Leg Ulcers

    • 2209 Words
    • 9 Pages

    Hack, A. (2003) Leg ulcers wounds - taking the patient 's perspective into account. Journal of Wound Care; 12: 8, 319-321.…

    • 2209 Words
    • 9 Pages
    Powerful Essays
  • Better Essays

    Seemingly unbearable smells, overweight patients, biohazardous material, infectious diseases, and sanitation are just some of the many things that we think of when we hear “Diabetic Ulcers”. Diabetic ulcers are just one of many issues that a diabetic patient may be prone to while treating their diabetes. Even though it is possible for a diabetic person to get an ulcer on any part of their body, the most common place an ulcer occurs is on the foot. A diabetic ulcer is defined as an ulcer or gradual disintegration or necrosis of skin tissue, usually of the lower extremities, associated with diabetes mellitus (medicaldictionary.com). There are several affects that can contribute to the onset of diabetic ulcers, but some of the most common are charcot, neuropathy, and peripheral artery disease. Most diabetic patients who have those affects are seen by a wound care specialist and/or podiatrist as a proactive measure to prevent serious complications such as diabetic ulcers.…

    • 1051 Words
    • 5 Pages
    Better Essays
  • Good Essays

    It believed that every 30 seconds a lower limb is lost somewhere in the world as a consequences of diabetes.(Jinada,C.et all 2009). In Tanzania 1% of population is said to have diabetic foot, and it estimated that over 27 percent of deaths among diabetic patients are attributed to diabetic foot (IDF, 2006) ignorance, life style changes, low socioeconomic status are mentioned to be main cause of diabetic foot (Smide, 2000).Now days the level of interest and knowledge on diabetic foot ulcers has developed much enough and evidenced base clinical practice has improved in treatment and prevention of diabetic foot. Although there is many difficult in implementation of foot care in patients which involves both health care professional and patients…

    • 208 Words
    • 1 Page
    Good Essays
  • Powerful Essays

    Rerkasem, K; Kosachunhanun, N; Tongpraser, S Khwanngern, K; Matanasarawoot, A; Thongchai, C; Chimplee, K Buranapin, S; Chaisrisawadisuk, S; Mangklabruks, A. et al chosen ”The nurse 's role in the prevention of diabetic foot ulcers” [Greek], retrieved from: www.cinahl.com/cgibin/refsvc?jid=3817&accno=2010055657…

    • 1778 Words
    • 8 Pages
    Powerful Essays
  • Powerful Essays

    “Is education fundamental to the prevention of diabetic foot ulcers?” This question was developed using the PICO framework (appendix one). Diabetes is a chronic condition that can have debilitating consequences that can seriously affect a patient’s lifestyle and their contribution to social gain according to the Department of Health and Children (D.O.H.C.) (2008). It is increasing at a rapid rate which is highlighted by The Institute of Public Health (2010) who state that the number of diabetics in Ireland will rise from 143,000 to 194,000 by the year 2015. This will result with more patients presenting with diabetic foot ulcers. Clair (2011) states, that one third of all diabetics are at risk of developing a diabetic foot ulcer and that between seventy to ninety percent of lower limb amputations are preceded by complication. This paper also revealed that every thirty seconds somewhere in the world a lower limb is amputated due to diabetes. The question for this assignment is focused in trying to establish if education is a tool that could aid in prevention of this complication. From clinical experience the author has noticed that when diabetics are on a ward it is mostly their blood sugars that are assessed and for which education is provided, with little regard for the patient’s feet.…

    • 1680 Words
    • 7 Pages
    Powerful Essays
  • Best Essays

    Evidence Based Practice

    • 4128 Words
    • 17 Pages

    Bell M (1994) Nurse’s knowledge of the healing process in venous leg ulceration. Wound care, 3 (3) pp. 145-150…

    • 4128 Words
    • 17 Pages
    Best Essays
  • Good Essays

    Operative Report

    • 510 Words
    • 3 Pages

    Postoperative Diagnosis: Diabetic plantar space abscess of the right foot, and grade 2 diabetic ulceration of the right foot.…

    • 510 Words
    • 3 Pages
    Good Essays