3-2 Office Visit - Established Patient Subjective: ThE PATIENT IS A 39-YEAR-Old fEMALE. I AM HER PRIMARY CARE PROVIDER. Patient states that she had onset YESTERDAY of SOME dizziness with vertigo. THESE SYMPTOMS continue throughout today. She feels that thE ROOM IS Spinning when she stands UP, ESPECIAlly on the left side. Onset Was At 2 PM YESTERDAY. SHE ARRIVED HOME At About 7 AM FROM HER Shift work. She has thrown UP A COUPLE of LIMES WITH PERSISTENT HEADACHES, WORSE with MOVEMENT. NO NECK PAIN. NO FEVER OR chills. SOME PARASPINAL TENDER- ness. No chest PAIN OR Shortness of BREATH. PAST MEDICAL history of hEAVY PERIODS, cholecystECTOMY REMOTELY. Objective: Vital Signs showed blood PRESSURE 113/74. RESPIRATORY RATE 18. Pulse 71. TEMPERATURE 97.3 on ROOM AIR. HEENT: CLEAR with PUPILS EQUAL, Round, And REACTIVE to light. Oropharynx clEAR. TYMPANIC MEMBRANES CLEAR. NECK: NO MASSES. HEART: REGULAR RATE And Rhythm. LUNGS: CLEAR to Auscultation bilATERAlly. AbdoEN: BENIGN. Skin: No RASHES. NEUROLOGICAL: CRANIAL NERVES II-XII intact. Strength is five Out of five In All EXTREMITIES. REFLEXES SYMMETRIC. CMP And CBC both RETURNED UNREMARKABLE. SHE WAS GIVEN 1 liter of LR; ZofRAN, 4 MG; And Benadryl, 50 MG. She felt MUCH BETTER After the Benadryl. A DIX HAllPIKE MANEUVER WAS PERFORMED which drastically REPRODUCED thE SYMPTOMS on the left side Expanded problem-focused history. Expanded problem-focused exam. Medical decision making of low complexity. Assessment: 1. Dizziness Plan: PATIENT WAS SENT HOME with SOME MECLIZINE. SHE WAS ENCOURAGED to consider Physical thERAPY for Vestibular Rehabilitation should SYMPTOMS WORSEN OR PERSIST. Steps: 1. In ICD-10-CM CODE book Look UP DIZZINESS 2. VERIFY code in tabular list 3. In CPT Code book DETERMINE PATIENT STATUS 4. DETERMINE PATIENT SERVICE 5. DETERMINE the level of history, EXAM And Medical deci- SION MAKING 6. VERIFY E/M CODE In tabular list What's your coding rationale? Diagnoses First Listed DX Procedures PPROC ICD-10-CM Codes CPT Codes Modifier (If Applicable)