Question

Code the E / M diagnosis Patient : Paige Holiday Paige comes in as a new patient having some vaginal discharge and itching . She denies any urinary problems . In August she had a bout of pancreatitis and is being treated for that by Dr. Guts . No other complaints . On examination , HEENT was normocephalic , atraumatic . Eyes and Ears unremarkable . Neck is supple . No thyromegaly or adenopathy . Lungs are clear Breasts are without palpable masses or discharge . No axillary adenopathy . Breast self - examination was reviewed . Her abdomen is soft and nontender . No hepatosplenomegaly . No groin adenopathy . Cervix , vulva and vagina without gross lesions . No discharge evident and no redness at this time . Uterus is anteflexed and mobile . I do not feel any adnexal masses . Pap performed . Wet prep of vaginal secretions positive for yeast . Gave her a slip for the mammogram . Impression : fungal vaginitis to candida . We will see her on a p.r.n. basis if discharge or itching return . Type answers in this order with a comma and a space between: One CPT , One CM

Answer 1

CPT code 99203 code description Detailed history, detailed examination, medical decision making of low complexity.

This code can be assigned as from the given data it shows that patient have visited the physician for first time, he collected history in detail as it is mentioned about past medical problems, ROS is done for less than 9 systems examination is detailed, MDM is made basing on reports and Chief complaints it's of low complexicity.

ICD 10 CM codes

B37. 3- candidiasis of vulva

Z87. 19-personal history of other diseases of digestive system. This code can be assigned as the patient had pancreatitis in past.