What First Listed Explained for Students (Easy Guide)

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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. ESTABLISHED PATIENT HISTORY OF PRESENT ILLNESS: Patient is a man who has a past medical history of hypertension for 15 years, elevated PSA, malignant neoplasm of colon, hearing loss and glaucoma who presented for evaluation of recent worsening of hypertension. According to the patient, he had stable blood pressure for the past 12-15 years on 10 mg of lisinopril. A few months ago, his blood pressure started to go up to over 200s. His lisinopril was increased to 40 mg daily. He was also given metoprolol and HCTZ two weeks ago, after he visited the emergency room with increased systolic blood pressure. Denies any physical complaints at the present time. Denies having any renal problems in the past. PAST MEDICAL HISTORY: As above. No smoking or alcohol use and lives alone. FAMILY HISTORY: Unremarkable. PRESENT MEDICATIONS: As above. REVIEW OF SYSTEMS: Cardiovascular: No chest pain. No palpitations. Pulmonary: No shortness of breath, cough, or wheezing. Gastrointestinal: No nausea, vomiting, or diarrhea. GU: No nocturia. Denies having gross hematuria. Salt intake is minimal. Neurological: Unremarkable, except for history of old CVA. PHYSICAL EXAMINATION: Blood pressure today is 182/78. Examination of the head is unremarkable. Neck is supple with no JVD. Lungs are clear. There is no abdominal bruit. Extremities 1+ edema bilaterally. LABORATORY DATA: Urinalysis done in the office shows 1+ proteinuria; same is shown by urinalysis done at Hospital. The creatinine is 0.8. Renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney. MRA of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis. IMPRESSION AND PLAN: Accelerated hypertension. No clear-cut etiology for recent worsening since renal artery stenosis was ruled out by negative MRA. I could only blame possible fluid retention as a cause of the patient’s accelerated hypertension. He was started on hydrochlorothiazide less than two weeks ago with some improvement in his hypertension. At this point, I would not pursue a diagnosis of renal artery stenosis. Since he is maxed out on lisinopril and his pulse is 60, I would not increase beta-blocker or ACE inhibitor. I will continue HCTZ at 24 mg daily. The patient was told to be strict with his salt intake. He will report to me in 10 days with the result of his blood pressure TOTAL TIME SPENT WITH PATIENT: 15 minutes

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