Case
-T6-1B OFFICE SERVICES
The same patient as in T6-1A presents for a visit post atherectomy after the days included in the surgical package.
LOCATION: Outpatient, Clinic
PATIENT: Bernie Lieberwitz
PHYSICIAN: David Barton, MD
The patient is here for a follow-up visit. He is a known patient with atherosclerotic heart disease, status post atherectomy of the right coronary artery back in 1997. He has been doing quite well with no complaint of chest pain or shortness of breath. He has been feeling a little bit light headed when getting up from a lying position. Cardiolite stress test last week came back normal.
PHYSICAL EXAMINATION: Blood pressure 122/70. Pulse 68. Head normocephalic and atraumatic. Neck supple without JVD (jugular vein distention) or bruit. Lungs are clear to auscultation and percussion. Heart: Regular S1 (first heart sound) and S2 (second heart sound); no S3 (third heart sound) or S4 (fourth heart sound). No clicks, rubs, or murmurs. Abdomen is soft and nontender. Bowel sounds are well heard. Extremities show no edema, cyanosis, or clubbing. CNS (central nervous system): Within normal limits. The patient is alert and oriented to time, place, and person.
ELECTROCARDIOGRAM is within normal limits.
ASSESSMENT: Coronary artery disease, status post atherectomy. Patient is doing quite well, with normal Cardiolite.
RECOMMENDATIONS:
1. Continue the current medication.
2. Repeat Cardiolite stress test on follow-up visit in one year.
T6-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question

Case
-T6-1B OFFICE SERVICES
The same patient as in T6-1A presents for a visit post atherectomy after the days included in the surgical package.
LOCATION: Outpatient, Clinic
PATIENT: Bernie Lieberwitz
PHYSICIAN: David Barton, MD
The patient is here for a follow-up visit. He is a known patient with atherosclerotic heart disease, status post atherectomy of the right coronary artery back in 1997. He has been doing quite well with no complaint of chest pain or shortness of breath. He has been feeling a little bit light headed when getting up from a lying position. Cardiolite stress test last week came back normal.
PHYSICAL EXAMINATION: Blood pressure 122/70. Pulse 68. Head normocephalic and atraumatic. Neck supple without JVD (jugular vein distention) or bruit. Lungs are clear to auscultation and percussion. Heart: Regular S1 (first heart sound) and S2 (second heart sound); no S3 (third heart sound) or S4 (fourth heart sound). No clicks, rubs, or murmurs. Abdomen is soft and nontender. Bowel sounds are well heard. Extremities show no edema, cyanosis, or clubbing. CNS (central nervous system): Within normal limits. The patient is alert and oriented to time, place, and person.
ELECTROCARDIOGRAM is within normal limits.
ASSESSMENT: Coronary artery disease, status post atherectomy. Patient is doing quite well, with normal Cardiolite.
RECOMMENDATIONS:
1. Continue the current medication.
2. Repeat Cardiolite stress test on follow-up visit in one year.
T6-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Quizplus · Accepted Answer

The Answer of Case
-T6-1B OFFICE SERVICES
The same patient as in T6-1A presents for a visit post atherectomy after the days included in the surgical package.
LOCATION: Outpatient, Clinic
PATIENT: Bernie Lieberwitz
PHYSICIAN: David Barton, MD
The patient is here for a follow-up visit. He is a known patient with atherosclerotic heart disease, status post atherectomy of the right coronary artery back in 1997. He has been doing quite well with no complaint of chest pain or shortness of breath. He has been feeling a little bit light headed when getting up from a lying position. Cardiolite stress test last week came back normal.
PHYSICAL EXAMINATION: Blood pressure 122/70. Pulse 68. Head normocephalic and atraumatic. Neck supple without JVD (jugular vein distention) or bruit. Lungs are clear to auscultation and percussion. Heart: Regular S1 (first heart sound) and S2 (second heart sound); no S3 (third heart sound) or S4 (fourth heart sound). No clicks, rubs, or murmurs. Abdomen is soft and nontender. Bowel sounds are well heard. Extremities show no edema, cyanosis, or clubbing. CNS (central nervous system): Within normal limits. The patient is alert and oriented to time, place, and person.
ELECTROCARDIOGRAM is within normal limits.
ASSESSMENT: Coronary artery disease, status post atherectomy. Patient is doing quite well, with normal Cardiolite.
RECOMMENDATIONS:
1. Continue the current medication.
2. Repeat Cardiolite stress test on follow-up visit in one year.
T6-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Case -T6-1B OFFICE SERVICES