Chapter 8, Problem 1CPTS

Please code the E/M code and any other procedures for the following case from your CPT coding book and add modifier if applicable: Location: Family medical center Encounter Date: 9/7/xx Provider: Snow Valley, MD Patient: Heather Williams Gender: F Age: 43-year-old established patient Chief Complaint: Rash, diabetes, HTN and shortness of breath after taking amoxicillin. Patient was placed in observation after an allergic reaction to the antibiotic. The amoxicillin was discontinued. Has severe dermatitis covering arms, stomach and legs. Patient was admitted to observation for further treatment and supervision. Later in the day the dermattis began fading and breathing became normal. Patient was discharged on the same date. Physician performed a detailed exam and a detailed history, and medical decision making was moderate. Diagnosis: Localized dermatitis and shortness of breath due to amoxicillin.

Case scenario:Client ERIC RAYMOND, 12 years old from CAA HOUSING, MANUYO DOS, Las Pinas City, was admitted in the hospital due to high grade fever for 4 days.Vital signs taken are as follows: BP 110/60, RR is 14, PR is 78 and Temp is 38.5. high grade feverWeight is 45kgs.Eric Raymond is known to have allergic reactions to eggs and seafoods but no known allergies to any medication.CBC / Platelet counts were requested laboratory test was done.Client Eric Raymond was admitted under the care of Dr. Rod Buenavista.Admitting diagnosis is Dengue Fever.Dr. Buenavista ordered the following.Start IVF of 1L of D5.09 NaCl to be infused for 8 hours. IVF started at 9amGive Acetaminophen 500mg q 4hrs.Repeat Platelet count after 8 hoursCBC and Platelet Result: (attached picture)Check Record vital signs*   Normal Abnormal Blood Pressure: 110/60     Temperature: 38.2 C     Respiratory Rate: 14 breaths per min     Pulse Rate: 78 beats per min     Check your lab results *   High…

Case scenario:Client ERIC RAYMOND, 12 years old from CAA HOUSING, MANUYO DOS, Las Pinas City, was admitted in the hospital due to high grade fever for 4 days.Vital signs taken are as follows: BP 110/60, RR is 14, PR is 78 and Temp is 38.5. high grade feverWeight is 45kgs.Eric Raymond is known to have allergic reactions to eggs and seafoods but no known allergies to any medication.CBC / Platelet counts were requested laboratory test was done.Client Eric Raymond was admitted under the care of Dr. Rod Buenavista.Admitting diagnosis is Dengue Fever.Dr. Buenavista ordered the following.Start IVF of 1L of D5.09 NaCl to be infused for 8 hours. IVF started at 9amGive Acetaminophen 500mg q 4hrs.Repeat Platelet count after 8 hoursCBC and Platelet Result: (attached picture)Computation 1 : Compute for the gtts/min (Drop factor is 15) Computation 2 : Compute for ml/hrComputation 3 : It is now 2:00PM how many should have been infused to the client?