CPT CODING

Due: Sunday, 24 September 2023, 11:55 PM

Value: 100 points—This assignment is worth 4% of the total grade.

Due: Day 7

Grading Category: Assignments

Instructions

The purpose of this assignment is to evaluate patient encounter notes and identify appropriate Current Procedural Terminology (CPT) codes to submit for billing. This is an important skill to master as a NP.

For this assignment, you will complete the Current Procedural Terminology (CPT) Coding Interactive.

Please refer to the Grading Rubric before starting.

  • This activity will walk you through patient scenarios and appropriate billing. You will have prompts to answer along the way.
  • When you have completed the activity, please print out your answers and upload the printout to this assignment for grading.

Please refer to the Grading Rubric for details on how this activity will be graded.

Remember that this assignment is complete at 100 points, so make sure you review all requirements and complete the assignment in its entirety. If the assignment is not complete, it is considered incomplete and will result in a 0.

Patient 1

Patient Name: Maria Rodriguez

  • Age: 25 y.o.
  • Ethnicity: Hispanic
  • Past Medical history: None
  • Past Surgical History: Tonsillectomy age 7
  • Medications: none
  • Family history: Mother Diabetes, Father Hyperlipidemia
  • Employment: works as a phlebotomist full time

Subjective:

Maria is an established patient who presents to office today for birth control. Pt is in a monogamous relationship with her current boyfriend of 4 months and is using condoms 100% of the time. Pt would like to start a more reliable form of birth control. Menarche 12 y.o menses: every 28 days and lasts for 5 days, patient denies cramps or irregular menses history. Patient is a non-smoker and does not use any substances. Last pap was 6 months ago negative for cytology. Gonorrhea and Chlamydia culture 6 months ago was neg/neg. HPV vaccine completed.

Objective:

  • 5 feet 6 inches 140 pounds 98.4-80-16-122/76
  • General: Healthy appearing Hispanic woman in no apparent distress
  • Skin: No skin lesions identified
  • Head: Normocephalic, good hair distribution, no alopecia no nits
  • Eyes: Symmetrical with no erythema or discharge. Vision grossly normal
  • Ears: Symmetrical with gross hearing intact
  • Nose: midline, no septal defect, no discharge
  • Mouth: good dentition, moist mucous membranes
  • Cardiac: HR 80 normal sinuses rhythm, no S3 or S4, no arrhythmias noted
  • Lungs: Clear to auscultation bilaterally A & P, no use of accessory muscles
  • Abdomen: flat, soft, non-distended. Bowel sounds active in all 4 quadrants, tympanic throughout, no hepatosplenomegaly, no rebound or guarding.

Assessment:

Contraception Counseling

Plan:

Diagnostics up to date

Patient Education: During the 20-minute face-to-face visit, I discussed with patient the various forms of contraception including barrier, hormonal, non-hormonal, abstinence and natural family planning. Discussed efficacy, cost, risks and benefits of each method, using the Birth control option handout. Discussed timing to start method and how to use method to ensure efficacy. Patient decided to start oral contraceptives. Discussed Sunday start, daily dosing, missed pills, common side effect and major side effects, such as ACHES and when to call.

  • Continue Condom use for STD prevention
  • Pharm: Ortho-Tricyclen 28 day, 1 pill every day to start on Sunday after first day of menses. 3 refills
  • Referrals: none
  • Follow- up: 3 months

Examining Medical Decision Making (MDM)

Remember 2 out of 3 MDM Elements must meet or exceed to determine Level of Service (LOS). 

 

These are the questions

question 1. 1.Complexity – Do you think this case is straightforward, low, moderate or high complexity? Support your claim with proof/rationale.  

question  2. Data Review – Did you review minimal or none, limited, moderate or extensive data? Support your claim with proof/rationale.  

3.What is the Risk of Morbidity from additional diagnostic testing or treating? (Minimal, Low, Moderate or High). Support your claim with proof/rationale.  

4.Given your above answers how would you code this patient?  

5.Is there any reason this patient might be billed based on time? If so, how might this change your coding?

 

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