Unit 7 Discussion – CPT E&M Code and ICD-10 Diagnosis Code
Instructions:
Use your lecture materials to determine what CPT E&M Code and ICD-10 diagnosis code to utilize for this ‘new patient’ encounter using the medical decision-making (complexity) approach.
Provide justification for the code you assigned by including the following information in your discussion:
Case:
This patient presents to a local health center. As the provider, you must conduct a full physical on the patient as well as a psychiatric intake.
Liam is a 22-year-old who reports to you that he feels depressed and is experiencing a significant amount of stress about school, noting that he’ll “probably flunk out.” He spends much of his day in his dorm room playing video games and has a hard time identifying what, if anything, is enjoyable in a typical day. He states once he leaves the room he begins sweating and feels as if he has heart palpations. He rarely attends class and has avoided reaching out to his professors to try to salvage his grades this semester. Liam has always been a self-described shy person and has had a very small and cohesive group of friends from elementary through high school. Notably, his level of stress significantly amplified when he began college. You learn that when meeting new people, he has a hard time concentrating on the interaction because he is busy worrying about what they will think of him – he assumes they will find him “dumb,” “boring,” or a “loser.” When he loses his concentration, he stutters, is at a loss for words, and starts to sweat, which only serves to make him feel more uneasy. After the interaction, he replays the conversation over and over again, focusing on the “stupid” things he said. Similarly, he has a long-standing history of being uncomfortable with authority figures and has had a hard time raising his hand in class and approaching teachers. He spends the majority of his day in his dorm room playing video games and struggles to determine what, if anything, is fun in a regular day. He claims that when he leaves the room, he starts sweating and gets heart palpitations. He rarely attends class and has avoided contacting his professors in an attempt to improve his marks this term. Liam has always regarded himself as timid, and he has had a very small and cohesive group of friends since elementary school. Notably, his stress level increased dramatically when he started college. You learn that when he meets new people, he has trouble concentrating because he is worried about what they will think of him – he assumes they will think him “stupid,” “boring,” or a “loser.” When he loses concentration, he stutters, is at a loss for words, and begins to sweat, which only adds to his unease. Following the discussion, he replays the conversation, focusing on the “dumb” things he said. Similarly, he has a long history of being uneasy around authority figures and has struggled with raising his hand in class and addressing professors.
Since starting college, he has been isolating more, turning down invitations from his roommate to go eat or hang out, ignoring his cell phone when it rings, and habitually skipping class. His concerns about how others view him are what drive him to engage in these avoidance behaviors. After conducting your assessment, you give the patient feedback that you believe he has social anxiety disorder, which should be the primary treatment target. You explain that you see his fear of negative Assessment, and his thoughts and behaviors surrounding social situations, as driving his increasing sense of hopelessness, isolation, and worthlessness.
Significant Symptoms:
• Anxiety
• Depression
• Ruminations
• Social Anxiety
• Physical symptoms; sweating, heart palpations
Vitals:
127/80
98
18
60
90%
BMI 30
225 lbs
72”
Physical exam:
General: Well appearing, well-nourished, in no distress. Oriented x 3, normal mood and affect. Ambulating without difficulty.
Skin: Good turgor, no rash, unusual bruising, or prominent lesions
Hair: Normal texture and distribution.
Nails: Normal color, no deformities
HEENT: Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring.
Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi have normal optic discs and vessels, no exudates or hemorrhages
Ears: EACs clear, TMs translucent & mobile, ossicles nl appearance, hearing intact.
Nose: No external lesions, mucosa non-inflamed, septum, and turbinates normal
Mouth: Mucous membranes moist, no mucosal lesions.
Teeth/Gums: No obvious caries or periodontal disease. No gingival inflammation or significant resorption.
Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate
Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged and non-tender
Heart: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop
Lungs: Clear to auscultation and percussion
Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia
Back: Spine normal without deformity or tenderness, no CVA tenderness
Rectal: Normal sphincter tone, no hemorrhoids or masses palpable
Extremities: No amputations or deformities, cyanosis, edema or varicosities, peripheral pulses intact
Musculoskeletal: Normal gait and station. No misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal strength or tone in the head, neck, spine, ribs, pelvis or extremities.
Neurologic: CN 2-12 normal. Sensation to pain, touch, and proprioception normal. DTRs normal in upper and lower extremities. No pathologic reflexes.
Psychiatric: Oriented X3, intact recent and remote memory, judgment and insight, anxious mood and affect.
Breast: No nipple abnormality, dominant masses, tenderness to palpation, axillary or supraclavicular adenopathy.
G/U: Penis circumcised without lesions, urethral meatus normal location without discharge, testes and epididymides normal size without masses, scrotum without lesions.
1. The level of medical complexity encompassed by including the number of points for the diagnoses/management options and the amount/complexity of data reviewed; then identify the level of risk for complications, morbidity, mortality
2. In the discussion explore how the I

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