Assignment task: A 69-year-old woman with past medical history of diabetes mellitus type 2, hypercholesterolemia, and hypertension is evaluated by her primary care physician because of a 6-month history of increasing anorexia, fatigue, and weakness. She has a history of systemic lupus erythematosus, well controlled for several years with hydroxychloroquine. The physical examination shows normal vital signs and no rash or joint effusions. Laboratory studies show a serum creatinine level of 1.4 mg/dL. A complete blood count (CBC) shows normal WBC count and platelets. Her hemoglobin is 9 g/dL. The mean corpuscular volume is 75 fL, the mean corpuscular hemoglobin concentration is 29 gm/dL, and serum ferritin is 9 ng/mL. Patient is currently experiencing homelessness. She is a new patient to the clinic.
The physician documents: outpatient visit for the evaluation and management of a new patient provided, diagnosed with colorectal malignancy with signs and symptoms of iron-deficiency anemia, specifically a low hemoglobin concentration with a low mean corpuscular volume (MCV) and a low mean corpuscular hemoglobin concentration, along with low ferritin.
What are the correct diagnosis and procedure codes (including E/M codes) for this patient? ICD-10-CM and CPT Code(s):