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. New patient Daniel Cook presentedto Dr. Lowell’s office today because he is new to the area andneeds to establish himself with a physician. He explained that hehas asthma for which he takes a prescription medication and that heis almost out of his medication. No medical history other thanasthma is reported, and old health records from his previousprimary care physician are unavailable. The review of systems ispositive for asthma. During today’s visit, the patient complainedof a sore throat and loss of appetite. These symptoms have beenpresent for four days, per the patient. The patient describes thesore throat pain as on and off with worsening in the morning andlate at night. The patient has taken only his prescribed asthmamedication. He has not taken any over-the-counter medications in anattempt to relieve the sore throat. The patient stated that heneeds a refill of his asthma medications, which the physicianprovided. The physician also instructed the patient to take Tylenolto relieve his sore throat symptoms and to eat foods that will notirritate his throat, such as soup. The patient was furtherinstructed that if the sore throat and loss of appetite did notabate in five to seven days, the patient should contact the officeto obtain a follow-up appointment. The physician documented adetailed examination and medical decision making of moderatecomplexity. (NOTE: Use the E/M CodeBuilder in Appendix I of yourtextbook to determine the level of history performed.)
