Description
Now, you?ve explained the E/M coding principles and guidelines, now it?s time to create some examples for your training document.
You will use Patient Case Number OPC120-Giles, Roderick as a coding example. You will need to:
- Discuss the four levels of the medical decision-making process and the management options.
- Code this case for accuracy and explain your process using ICD-10-CM and CPT E/M codes.
OPC120GilesRoderick
Outpatient Consultation
Patient Case Number: OPC120-Giles, Roderick
Patient Name: Roderick Giles
DOB: 11-04-65
Sex: M
Date of Service: 08-11-XX
Physician: Samuel Stiles, MD
Chief Complaint: Bilateral hand pain
History of Present Illness: I am seeing Mr. Giles at the request of Dr. Stiles who was last seen in the
office about 3 months ago. He is a pleasant 53 y/o man with a history of RA and is currently on Humira
and Sulfasalazine. He was also on MTX but was stopped because of lung problems. He also has lung
lesions that are being followed by pulmonary. He was cleared to restart Humira after his hospitalization.
He does not believe that his Humira is working for him. He has been on Humira for some time, and
does not believe he has had any benefit. He is due for his TB test. He would like to discuss switching
medications. He rates his pain as an 8/10, and has morning stiffness for about 4 hours each morning.
Past Medical History: RA, DDD (lumbar) Family History: noncontributory
Social History: no smoking; no alcohol use.
Medications: Humira, Sulfasalazine, Prednisone, Ibuprofen
Allergy: Augmentin, Penicillin.
Review of Systems:
Constitutional: Denies fatigue, unintentional weight loss, fever, chills
HEENT: Denies headache, dizziness, sore throat
Cardio: Denies chest pain, palpitations
Lungs: Denies SOB, cough
Gastrointestinal: Denies nausea, abdominal pain, diarrhea
Genitourinary: Denies hematuria, dysuria
Skin: No rashes Heme: No bruising. Neuro: No paresthesia Psych: Negative
Vitals:
Temperature
Pulse
Respirations
98.6?F
68
20
MCCG240 Case Scenario OPC120 Giles, Roderick.html[10/21/2021 11:05:07 AM]
OPC120GilesRoderick
Blood Pressure
Height
Weight
BMI
125/60
6?0ft
200lbs
27.1
Physical Examination:
Head: normocephalic.
ENT: No signs of acute inflammation.
Neck: Supple, no LAD
Heart: RRR without murmur click or rub. No ectopics appreciated.
Lungs: CTA.
Abdomen: Soft non-tender, without organomegaly.
Extremities: No rash or significant peripheral edema. Distal neurovascular exam is intact without
cyanosis or clubbing.
Musculoskeletal: Axial Skeleton: Cervical spine has no tenderness to palpation Peripheral
Musculoskeletal: Tenderness and synovitis of MCPS 2, 3 ,4 bilaterally. Neuro: Non-focal.
Psych: Normal affect and mood.
Impression:
1. RA involving both hands
2. DDD of lumbar spine
Plan:
Patient presents to clinic today for RA. At this time, he does not believe Humira has helped him at all.
He would like to consider other options. Discussed Enbrel, Actemra, and Xeljanz with him. He would
like to try Enbrel. Discussed dosing, side effects, and also monitoring with him. He will continue on
Sulfasalazine. He is due for his TB test, and this will be done today. He will have his wash out period of
Humira that will end in a couple weeks, and he can start Enbrel after that. Will give him prednisone 5mg
daily during the wash out period. Discussed exercise and pool aerobics.
Total time spent with patient more than 60 minutes.
Electronically Signed By: Samuel Stiles, MD
Copyright ? 2020 by The American Health Information Management Association. All Rights Reserved.
MCCG240 Case Scenario OPC120 Giles, Roderick.html[10/21/2021 11:05:07 AM]
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