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 VISITPATIENT: JEFFREY OFFICERECORD NUMBER: 10-68-23DATE OF SERVICE: 03-23-XXPHYSICIAN: DR. KIM. M. D. SUBJECTIVE: This established patient came in today for administrative purposes. A letter was dictated on his behalf to a claims examiner who is determining employability for the patient. The patient has not been employable for more than a decade due to chronic pain issues. He is having increased pain in his right leg now above and beyond the chronic nerve pain in his left leg, which has had an amputation.
OBJECTIVE: On examination today, it looks as though he has got some evidence of partial quadriceps tearing in the right thigh. Right now, he does not want to pursue that further. I agreed, and we can wait and see what happens. This man has a hard enough time getting around now as it is, and I think he is just slowly but surely wearing his knees out. He has partially torn his quadriceps on the right thigh with neurologic effects. He has had some chronic back pain, and at some point he may need further workup.
ASSESSMENT: - Chronic nerve pain due to right leg amputation 11years ago.
- Partially torn quadriceps right thigh.
- Chronic back pain.
PLAN: For now, I simply recommend that he continue with his chronic pain management as he is. Recheck is planned from our viewpoint on an as-needed basis.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
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