Physician Office Certified Explained for Students (Easy Guide)

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Original Question

You are a physician’s office Certified Lead Coder for ABC Medical Group. As a Lead Coder, you are responsible for onboarding new Certified Coders. Certified Coders review patient records, identify what information they need to abstract from the documentation, and then assign the correct code(s) to that information. One of the important reasons of accurate code assignment is to ensure that services rendered are reimbursed appropriately. As Certified Lead Coder, you have been tasked with creating a coding training aid for new Certified Coders that will contain codes for a patient’s diagnosis, procedures completed, and/or equipment used. To do this training aid, you must review the provided patient’s records and assign appropriate codes. assign the appropriate CPT code(s) on the template provided. Physician’s Office Progress Note Chief Complaint: Jane Smith is a 55-year-old female presenting today for a follow up of her recurrent diagnosis carcinoma of the left breast. She completed treatment two years ago and now has recurred. She received a screening mammogram a month ago that revealed a cluster of suspicious calcifications. She followed up with a diagnostic mammogram with a sterotactic core needle biopsy that was sent for pathologic evaluation and revealed carcinoma of the left upper quadrant breast. Past Medical History: Depression- Patient is on Zoloft 100mg daily and is being followed by her PCP. Hypertension- Patient is on Lisnopril daily and is being followed by her PCP. Family Medial History: Mother- history of breast cancer Father- none Review of Systems CONSTITUTIONAL: No weight loss, fever, chills, weakness or fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: Currently on Zoloft, patient is somewhat tearful in the office. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: No history of asthma, hives, eczema or rhinitis. Physical Examination: GENERAL APPEARANCE: Well-nourished female in no acute distress. VITAL SIGNS: Blood pressure 110/72, pulse rate 64 beats per minute, temperature 98.4 degrees Fahrenheit, and SpO2 saturation 99%, weight 165 lbs. HEENT: Normocephalic and atraumatic. No scleral icterus. Pupils are equal, round, and reactive to light and accommodation. No conjunctival injection is noted. Oropharynx is clear. Mouth revealed good dentition, no lesions. Tympanic membranes are clear. NECK: Supple. Trachea is midline. No evidence of thyroid enlargement. No lymphadenopathy or tenderness. CHEST: Symmetric. Nontender to palpation. LUNGS: Breath sounds are equal and clear bilaterally. No wheezes, rhonchi, or rales. HEART: Regular rate and rhythm with normal S1 and S2. No murmurs, gallops, or rubs. BREASTS: Symmetrical. No skin or nipple retractions. No nipple discharges or masses. ABDOMEN: Soft, flat, and benign. No mass, tenderness, guarding, or rebound. No organomegaly or hernia. Bowel sounds are present. No CVA tenderness or flank mass. EXTREMITIES: No cyanosis, clubbing, or edema. Plan and Assessment: That patient and I discussed in great detail different options regarding next steps. Because this is recurrent, the standard of care would be to complete a mastectomy and sentinel lymphadenctomy. I would like her to receive a CT PET scan to ensure the cancer has not metastasized as well as follow up with a plastic surgeon to consider breast reconstruction. Because patient is tearful, I would like her to see our onsite therapist to assist with coping skills related to her depression. 25 minutes spent with patient. Electronically Signed by: Dr. Michael Wells, MD 10:00 AM 3/2/XX

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