Outpatient Physician Practice Question & Answer Guide (With Explanation)
Understanding this question requires applying core subject principles.
What This Question Is About
This question relates to outpatient physician practice and requires a structured academic response.
How to Approach This Question
Break the problem into smaller parts and analyze each logically.
Key Explanation
This topic involves outpatient physician practice. A strong answer should include explanation, application, and examples.
Original Question
If Outpatient/ED/Physician practice what is the patient’s Primary Diagnosis in words, followed by the ICD code? Are there any secondary diagnosis(es) (if any) in words that should be coded? You are responsible for knowing and understanding the definition of a secondary diagnosis that needs to be coded as well as sequencing guidelines. What is/are the corresponding ICD code(s) for the diagnosis(es). Are there any procedures that need to be coded; if so, code them in the proper order, using the proper coding system. TYPE, IN PROPER ORDER, THE DIAGNOSIS AND PROCEDURE CODE(s) for CASE 1 are: HISTORY OF PRESENT ILLNESS: The patient denies fever, chills, nausea, vomiting, chest pain, shortness of breath, or changes to his medication. He also denies any other new symptoms. The patient also denies resting tachycardia, orthostatic light headedness, early satiety, early morning nausea, changes in bowel habits, or postprandial sweating. The patient states his foot has been “asleep” for the past 5 years. The patient denies the use of alcohol and tobacco. HISTORY: Patient was diagnosed with Type 2 diabetes at the age of 33 and has been insulin-dependent for the last 5 years. He has congestive heart failure, hypertension, peripheral arterial disease of bilateral lower extremity, DPN, diabetic foot ulcers, Charcot foot deformity, a partial fifth ray amputation, and a kidney transplant from a nonmatched donor. The patient’s glycemic control had never been optimal despite medications and a multiple-dose insulin program. His hemoglobin A1C levels have typically been in the 8-9 percent range. CURRENT MEDICATIONS:The patient takes 18 different medications including two different immunosuppressive medications as well as Prednisone due to his kidney transplant. He is also taking an angiotensin-converting enzyme inhibitor for hypertension. ALLERGIES: NKA EXAM: Findings remain unchanged from his last visit 3 months ago. He is a moderately overweight (BMI 30 kg/m2 ) man with a blood pressure of 131/85 mmHg with no orthostatic change and a resting pulse of 72 with no change with Valsalva maneuver.
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