Use the case below to assign ONLY CONFIRMED DIAGNOSIS CODES as well as the the E/M code. SUBJECTIVE: A 54-year-old patie

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Use The Case Below To Assign Only Confirmed Diagnosis Codes As Well As The The E M Code Subjective A 54 Year Old Patie 1 (51.07 KiB) Viewed 28 times

Use the case below to assign ONLY CONFIRMED DIAGNOSIS CODES as well as the the E/M code. SUBJECTIVE: A 54-year-old patient is seen in the office by an Primary Care Provider for evaluation and management of type 1 diabetes mellitus; the patient also has hypertension. The patient has no new complaints today and denies chest pain, headache, numbness of the extremities, shortness of breath, or visual changes. The patient has remained on the diet recommended during the last E/M visit with the PCP and regular exercise is part of the daily routine. Home monitoring of blood pressure and glucose levels are within normal limits. OBJECTIVE: Blood pressure 130/78, Weight 145. Pulse 78, regular. HEAD, EYES, EARS, NOSE, THROAT: Pupils equal, round, and reactive to light and accommodation. External auditory canals and tympanic membranes negative. Oropharynx benign. NECK: Supple. No bruits, jugular venous distention, or thyromegaly. CHEST: Breath sounds clear to auscultation and percussion. No rubs, rales, rhonchi, or wheezing. HEART: No click, gallop, irregularity, murmur, or rub. EXTREMITIES: Distal pulses intact. No cyanosis, clubbing, or edema. NEUROLOGICAL: Deep tendon reflexes within normal limits and symmetrical. No decreased lower extremity sensation noted. LAB RESULTS: Fasting blood sugar 132. Urinalysis within normal limits. ASSESSMENT: Type 1 diabetes mellitus, controlled. Hypertension. PLAN: Glucotrol 5 milligrams daily, every morning. Procardia XL. 30 milligrams daily. Relafen 1,000 milligrams daily. Continue home glucose monitoring, SMA-7 and glycosylated hemoglobin today. Return for routine follow-up in three months. Use the editor to formot your answer