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Read Unit 6-MC165-020 Download Unit 6-MC165-020case study and abstract the information. What CPT code should be reported? Patient Type: Established Patient, Office Visit Reason for Visit: Vaginal itching and pain Unit-Case Study No: Unit 6-MC165-020 Chief Complaint: 42-year-old established patient presents for an office visit. She has complaints of severe vaginal itching and moderate pain. History & Exam: During the medically appropriate history and exam the patient states that several weeks earlier she had noted a slight itching which increased in severity. Yesterday, she noted a lesion on her genitalia. Buring and painful urinations have increased over the past six day accompanied by rectal itching. She has tried a variety of OTC ointments and creams, which induced no improvement. The patient states that she has had several yeast infection in the past that had been successfully treated by her previous physician. Personal history indicates several prior urinary infections. No discharge noted. An examination of the external genitalia revels a lesion, which had previously reputured, located on the vulva. Bacterial and viral smears are done. Medical decision-making is straightforward. Plan: The patient is advised the smears would be back in 24 hours and that a treatment plan would be developed based on the test results. Smear Results: positive for a bacterial infection, for which antibotics were prescribed. CPT CODE

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