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:GREGORY OFFICE
RECORD NUMBER:00-15-91
DATE OF SERVICE:02-02-XX
PHYSICIAN:DR. KIM. M. D.
S:The 33-year-old male patient comes in stating that for the last 2weeks his rectum has been bothering him. It hurts him to have a bowel movement. He occasionally gets blood when he wipes and occasionally has blood in the stool. He has had hemorrhoids before and this kind of feels like it. He has not really had any constipation.He has had no abdominal pain or other problems such as this. It just seems to be bothering him.
O: Vital signs as per chart. Abdomen is soft.
A:Hemorrhoids.
P: We are going to put him on Anusol suppositories one twice a day and given six. We are going to have him use Anusol cream applied four to five times a day as needed.He is to wipe very gently and maybe even just wash with water.He can use witch hazel pads and go that direction.Ifit is not getting better or if he is having more problems, he is to let us know.Otherwise, he is to follow up, as he feels necessary.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
APC: _____________________
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