Assignment Instructions: Assign the appropriate CPT E & M level, procedures and ICD-10-CM code(s) for the physician office encounter. When there are multiple CPT codes, always sequence E & M level first. When there are multiple ICD-10-CM codes, sequence first-listed diagnosis first.
New patient presented to Dr's office today because he is new to the area and needs to establish himself with a physician. He explained that he has asthma for which he takes a prescription medication and that he is almost out of his medication. No medical history other than asthma is reported, and old health records from his previous primary care physician are unavailable. The review of systems is positive for asthma. Exam showed some minimal wheezing present in the left lung, and some mild diminished breath sounds. During today's visit, the patient complained of a sore throat and loss of appetite. These symptoms have been present for four days, per the patient. The patient describes the sore throat pain as on and off with worsening in the morning and late at night. The patient has taken only his prescribed asthma medication. The patient stated that he needs a refill of his asthma medications, which the physician provided. The physician also instructed the patient to take Tylenol to relieve his sore throat symptoms and to eat foods that will not irritate his throat, such as soup.
Assign code(s) for physician services.
ICD-10-CM first-listed diagnosis: ________
CPT: ________
Please select all secondary diagnosis(es) that apply.
Top of Form
a. J02.9
b. J31.2
c. J45.901
d. J44.0
e. J45.902
f. R63.0