Assign the ICD-10-CM code(s) according to outpatient codingguidelines (e.g., assign codes to signs and symptoms when adiagnosis has not been established), and assign the CPT evaluationand management code(s) and appropriate modifier(s). Do not assignICD-10-CM external cause codes. . Mrs. Austin has been a residentof a nursing facility for the past year due to Alzheimer’s disease.Today during this month’s follow-up visit by her primary carephysician, she was seen for a chief complaint of difficultysleeping. The patient states that she is sleeping only a few hourseach night and often awakens around 3 AM and is unable to go backto sleep. The primary care physician prescribed medication to treatthe patient’s inability to sleep, and he reviewed the patient’sAlzheimer’s disease prescription medications to ensure that noadverse reaction would result from her taking the prescribed sleepmedication. He documented a problemfocused history, a detailedexamination, and medical decision making of low complexity.
