Code the following cases for outpatient facility purposes using ICD-9-CM, ICD-10-CM, and CPT codes. Sequence codes in the correct order.
Calculate the APC.
Assign modifiers when appropriate.
Use external cause codes when appropriate.
Do NOT code procedures that are captured by the facility chargemaster.
EMERGENCY DEPARTMENT VISIT
PATIENT: MAXOFFIE
RECORDNUMBER: 08-68-23
DATEOFSERVICE: 04-16 XX
PHYSICIAN: DR. KIM. M. D.
SUBJECTIVE: This 28-year-old maleestablished patient presents to the emergency department because of urticaria since last night. There are two issues that might have occurred. He ate an apple last night that seemed to be imperfectly ripe. It might not have been washed. The second is he has had a cat for the past couple of days that seems to want to sleep on his bed and be near him that used to always be inside but now it goes outside and plays and rubs in the bushes, then comes back inside. The patient denies allergies, or taking any current medications. Patient denies any previous illnesses.
OBJECTIVE: Physical examination reveals urticaria present over patchy surface areas of his body. The lungs are clear to auscultation. Cardiac exam is normal.
lMPRESSlON: Allergic urticaria, probably food induced or cat induced.
PLAN: I gave him an injection of Benadryl and epinephrine. We are going to do oral Benadryl 50 mg tidprn and prednisone 40, 30, 20, and 10 mg q. day for 4days. The patient is instructed to see an allergist for a complete allergy workup.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
APC: _____________________
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