S: A new patient was seen today in the GI clinic for a level 2 visit. She complains of one week of severe epigastric pain and burning, especially after eating.

O: On examination there is extreme guarding and tenderness, epigastric region, with no rebound. Bowel sounds are normal. BP 110/70.

A: Rule out gastric ulcer.

P: The patient is to have upper gastrointestinal series. Start on Zantac and eliminate alcohol, fried foods, and caffeine. Return in one week.

CPT/HCPCS Level II Codes ICD-10-CM Codes

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