3-2-1 Code It
6th Edition
ISBN: 9781337660549
Author: GREEN
Publisher: Cengage
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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.
A 59- year- old woman with a history of cardiac disease is scheduled for modified radical mastectomy. Describe the preoperative and postoperative care of this patient, including discharge planning.
Case Scenario
A 25-year-old woman delivered 2 weeks ago. She states that she has been breastfeeding with no problems until two days ago. Now she is complaining of right breast tenderness, pain and redness. Her temperature is now 38.5 degree celcius.
GUIDE QUESTIONS:
What do you think is happening to the client? Explain further.
What are the nursing interventions and treatment for this condition?
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