Code the following physician encounters using ICD-9-CM, ICD-10-CM, and CPT. Sequence the codes in the correct order. Assign any needed modifiers.
PHYSICIAN OFFICE VISIT
PATIENT: SHELBYOFFICE
RECORD NUMBER: 04-68-23
DATE OF SERVICE: 03-15-XX
PHYSICIAN: DR. KIM, M. D.
SUBJECTIVE: The patient is a 34-year-old female established patient who presents with several days of malaise, generalized abdominal pain, and nausea. She states that for about 3days now, she has had an achy feeling associated with a headache and some chills. She has had transient intermittent abdominal pain as well in multiple areas, no one area. She has had some loose bowel movements. She was nauseated somewhat and vomited once.
OBJECTIVE: On examination, she is noted to have normal vital signs with the exception of a low-grade fever of 100. 6. She is noted to have clear lung fields bilaterally. Examination of the abdomen reveals hyperactive bowel sounds but no tenderness and there is no organomegaly. Thereis no costovertebral angle tenderness. HEENT: The throat is no erythematous. Mouth shows normal mucosa with adequate saliva. The neck is supple. Extremities are unremarkable.
ASSESSMENT: Viral gastroemeritis.
PLAN: Fluid, clear liquid diet with increased amounts of clear liquids frequently. Tylenol or aspirin as needed for malaise or fever. Darvocet-N 100 small prescription of 10 is written to take as needed for abdominal pain. Recheck if not improving after the next three or so days.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
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