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Original Question
1) What is the ICD-10-CM first-listed diagnosis code? 2) What are the secondary diagnosis codes? (there are 0) 3) The principal CPT procedure code? (CPT’s 10004-69990) enter the CPT, otherwise enter the correct E/M CPT code 4) Secondary Procedure Code(s) LEAVE THIS BLANK or enter the CPT code if secondary surgical procedure is performed. NEW PATIENT VISIT CC: (In husband’s words) My wife seems tired and unhappy to be a mother S: Angela is a Spanish-speaking (speaks very little English) Mexican immigrant who delivered her first child via uncomplicated spontaneous vaginal delivery five weeks ago. Both mom and baby are doing well physically. Dad (husband) brings Angela to the clinic today with complaints that his wife is unhappy and doesn’t seem to enjoy being a mother but would rather sleep and sit. He blames the lack of a proper la cuarenta, a 30-day postpartum rest period that is traditionally facilitated by the women of the extended family. The Flores’s do not have any other family in the area and Angela only came to the U.S. this year. Miguel is working long hours in an electrical business and Angela is at home caring for the baby alone during the day. Mom started breastfeeding in the hospital but stopped after baby seemed colicky at home. Baby is taking regular bottles of iron-rich formula and is sleeping 1- 3 hours at a time, with normal growth and development. I am able to ask Angela a few questions in Spanish alone when her husband needs to leave to change the baby’s diaper. She feels safe in her home and says she is just lonely. She is not sure how she should feel as a mother because she has never been one and has no one to talk to. She does not drive or speak English and does not leave the house. O: Young, Latin female sits quietly in the exam room next to husband. Holds baby on lap and soothes child when needed. Husband is animated and does most of the talking. Patient is very composed and reserved. Does have appropriate dress and effect. A: Feelings of sadness and loneliness in a young, isolated new mother. R/O Postpartum Depression. P: Referral to therapy for further assessment. Needs to administer 35-item Postpartum Depression Scale (PDSS) Beck 2008a which is available in Spanish, I do not have this scale, psychologist will need to administer it at the next available appointment. TOTAL TIME SPENT WITH PATIENT: 30 minutes
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