1. What is the E&M code ? 

2. What is the diagnosis code ?

3. what is the 2 CPT codes for this visit?

 

Patient: Missy Blood 

HISTORY OF PRESENT ILLNESS: This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone. Overall, she tells me that now she feels quite well. Repeat CBC showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000. 

CURRENT MEDICATIONS: Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.

ALLERGIES: No known drug allergies

REVIEW OF SYSTEMS: As per the HPI , otherwise negative.

PAST MEDICAL HISTORY: 1. Status post 

tonsillectomy

 2. Status post hysterectomy . 

3. Status post bilateral cataract surgery. 

4. Esophageal stricture status post dilatation approximately four times.

 SOCIAL HISTORY : She has no tobacco use. She has rare alcohol use. She has three children and is a widow. Her husband died after they were married only eight years. She is retired . 

PHYSICAL EXAM: VIT: Height 167 cm , weight 66 kg blood pressure 122/70 , pulse 84, and temperature is 98.9 

GEN: She is nontoxic , noncachectic appearing.

HEAD: Examined and normal. 

EYES: Anicteric . 

ENT: No oropharyngeal lesions

LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy.

HEART: Regular S1, S2; no murmurs , rubs, or gallops 

LUNGS: Clear to auscultation bilaterally ABDOMEN: Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly 

EXT: Reveal no edema. 

ASSESSMENT/PLAN: Idiopathicaplastic anemia. I am going to repeat her CMP today to assess her kidney function. We will continue with monthly CBCs for now and I will see her again in one month