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Coding Case
1. The potential ICD-10 codes for this case may include:
N76.0 Acute vaginitis
N76.1 Subacute and chronic vaginitis
N39.0 Urinary tract infection, site not specified
Z30.09 Encounter for initial prescription of other contraceptives
Z87.891 Personal history of appendectomy
Z83.41 Family history of diabetes mellitus
2. When a patient seeks care at a clinic or medical practice, the provider will typically document the patient's medical history, including any previous visits or encounters. This medical record serves as a repository of information about the patient's health and care, including diagnoses, treatments, medications, and other relevant information. When a patient returns to the clinic or medical practice for follow-up care, the provider can review the patient's medical record to see what has been documented previously. If the patient has been seen at the clinic before, the provider can use this information to guide their evaluation and management of the patient. The provider can also use this information to determine if the patient is a new or established patient for billing and coding purposes. In general, a patient is considered a new patient if they have not received any services from the provider within the past three years (Bajowala et al., 2020)....…Examination is the most appropriate code to use for billing and coding purposes in this case (Huang et al., 2019).
5. To determine the decision-making level for coding the visit, the NP would consider the number and complexity of the problems addressed during the encounter, the amount and complexity of data reviewed and analyzed, and the risk of complications or morbidity from the patient's presenting problem. In this case, the NP addressed one problem (vaginal discharge and UTI), reviewed and analyzed moderate amount and complexity of data from laboratory tests, and the risk of complications or morbidity was moderate. Therefore, the NP would choose a…
References
Bajowala, S. S., Milosch, J., & Bansal, C. (2020). Telemedicine pays: billing and coding update. Current Allergy and Asthma Reports, 20, 1-9.
Huang, E. Y., Knight, S., Guetter, C. R., Davis, C. H., Moller, M., Slama, E., & Crandall, M. (2019). Telemedicine and telementoring in the surgical specialties: a narrative review. The American Journal of Surgery, 218(4), 760-766.
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Medicare and Medicaid Services (CMS) announced in January that ICD- 10-CM will be implemented into the HIPAA mandated code set on Oct. 1, 2013. Introduction to the new structure of ICD manual o Statistics The International Classification of Diseases (ICD) is a program that is designed in order to record statistics of morbidity and mortality and for the indexing of hospital records of disease. ICD is published by the World Health Organization
CPT Codes CPT coding is a fact of life in the provision of healthcare today. CPT stands for Current Procedural Terminology, and is a system first developed by the AMA (American Medical Association) in 1966 "to convert widely accepted, uniform descriptions of medical, surgical and diagnostic services rendered by healthcare providers into five-numeric codes" (Medical Coding Experts, p. 1). CPT codes are necessary in order for accurate reimbursement to be obtained
State Elder Rights and Legal Assistance Development Program were also included in Title VII of the Act. In 2006, the phrase "assisted living facility" was added to the definition of "long-term care facility" (Ombudsman Program Provisions in the Older Americans Act, 2010). All these provisions were aimed at better care for the elderly in the United States. 3 Effective communication is a vital element of all human relationships (Winbow, 2002). It
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