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.Kate Martin is a long-time patientof Dr. Hardy’s office, and she presents to the office today withthe complaint of “feeling very tired all of the time even aftersleeping for eight hours:’ The patient reports that she has beenfeeling this way for the past three weeks. The physician documenteda detailed history, an expanded problem focused exam, and medicaldecision making of low complexity.
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