Hi, please can you help me with this case of coding and billing, is my first time on this.

5-6 EMERGENCY DEPARTMENT SERVICES

LOCATION: Hospital Emergency Department

PATIENT: Shelly Porch

PHYSICIAN: Paul Sutton, M.D.

SUBJECTIVE: This patient is a 37-year-old female who reports she was feeling well until yesterday, when she developed some dizziness, which has persisted. She also feels like something is "sticking" in her throat. She is concerned that she may have a thyroid problem. She has a history of hypothyroidism for which she is on Synthroid 0.125 mg q.d.Her last TSH level was done three months ago, and at that time was normal at 0.57.

OBJECTIVE: White female who appears to be in general good health. Her blood pressure is 118/82, Respiratory 20s, Afebrile. HEENT is unremarkable. Neck is supple. No masses. No palpable thyromegaly, nodules, or tenderness. TSH level is elevated at 11.77.

ASSESSMENT: Hypothyroidism.

PLAN: We will increase Synthroid to 0.15 mg q.d. Recommend follow-up TSH level in 3 months with her primary physician.