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. 8. Ms. Hardy was seen in Dr.Stockwell’s office. This patient was referred by her primary carephysician due to complaints of muscle weakness and diplopia. Theconsulting physician, Dr. Stockwell, documented a comprehensivehistory, a detailed examination, and medical decision making ofmoderate complexity. 9. A patient presented to her familyphysician’s office with the chief complaint of aching muscles. Thepatient has fibromyalgia and was last seen two months ago forexacerbation of her symptoms. The physician documented a detailedhistory, a comprehensive examination, and medical decision makingof moderate complexity. 10. The attending physician was preparingto discharge a patient for an inpatient hospital stay, during whichtime the patient’s acute bronchitis was treated. The physicianexamined the patient and reviewed discharge instructions with thepatient and the family. The physician also contacted home healthservices for the patient’s continued care. The total time spentdischarging the patient was 45 minutes.
