PATIENT: OLDAKER, WALLACE

ACCOUNT/EHR #: OLDAWA001

DATE: 10/15/18

This patient is a 53-year-old male who presents with complaints of persistent pain in both feet, which has been going on for the last 2 months. He states he has had to take Tylenol #3 to help alleviate the pain. I last saw this patient three months ago, he was stable at that time.

HISTORY OF PRESENT ILLNESS: The patient denies fever, chills, nausea, vomiting, chest pain, shortness of breath, or changes to his medication. He also denies any other new symptoms. The patient also denies resting tachycardia, orthostatic lightheadedness, early satiety, early morning nausea, changes in bowel habits, or postprandial sweating. The patient states his foot has been "asleep" for the past 5 years. The patient denies the use of alcohol and tobacco.

HISTORY: Patient was diagnosed with Type 2 diabetes at the age of 33 and has been insulin-dependent for the last 5 years. He has congestive heart failure, hypertension, peripheral arterial disease of bilateral lower extremity, DPN, diabetic foot ulcers, Charcot foot deformity, a partial fifth ray amputation, and a kidney transplant from a nonmatched donor. The patient's glycemic control had never been optimal despite medications and a multiple-dose insulin program. His hemoglobin A1C levels have typically been in the 8-9 percent range.

CURRENT MEDICATIONS: The patient takes 18 different medications including two different immunosuppressive medications as well as Prednisone due to his kidney transplant. He is also taking an angiotensin-converting enzyme inhibitor for hypertension.

ALLERGIES: NKA

EXAM: Findings remain unchanged from his last visit 3 months ago. He is a moderately overweight (BMI 30 kg/m2) man with a blood pressure of 131/85 mmHg with no orthostatic change and a resting pulse of 72 with no change with Valsalva maneuver.

EXTREMITIES: Decreased position sense as well as absent sensation to 10-g monofilament testing.

RX: 5% lidocaine patch (Lidoderm, Endo Pharmaceuticals) twice daily for 5 weeks to treat the neuropathy because of the drug's lack of serious toxicity and drug interactions.

Schedule next office visit for 45 days.

I need help finding the icd 10 and CPT codes

You're looking for:

Six ICD-10-CM diagnosis codes.o Be sure to take a look at the diabetes section in the tabular to refresh your memory on what conditions can be combo-coded with type 2 diabetes.o Be sure to look at all the instructional notes at the base codes.o The 3M encoder should be able to lead you through this one. When you get to the end, be sure to evaluate whether the codes 3M give you fit the documentation. There's one that you may need to adjust. You decide how many CPT procedure codes.