AAPC - Chapter 19 Practical Applications

CASE 2 Susan is a 67 years-old female and she is referred by Dr. R with a suspicious neoplasm of her left arm.(Chief Complaint) She has had it for about a year but it has grown a lot this last few months. (Related to surgery.) I had the privilege of taking a skin cancer off her forearm in the past. (Established patient.) PAST MEDICAL HISTORY: Hypertension, arthritis. ALLERGIES: None. MEDICATIONS: Benicar and Vytorin. SOCIAL HISTORY: Cigarettes: None. PHYSICAL EXAMINATION: On examination, she has a raised lesion. It is a little bit reddish and is on her left proximal arm. It has a little bumpiness on its surface. (Related to surgery.) MEDICAL DECISION MAKING: Suspicious neoplasm, left arm. My guess is this is a wart, but it may be a keratoacanthoma (Possible diagnoses are not coded.) as Dr. R thinks it is. After obtaining consent, we infiltrated the area with 1cc of 1% lidocaine with epinephrine, performed a 3-mm punch biopsy of the lesion, and then I shaved the rest of the lesion off and closed the wound with 3-0 Prolene.(Punch biopsy and shaving of the lesion are performed.) We will see her back next week to go over the results. What are the CPT® and ICD-10-CM codes reported?

11300 D49.2 Z85.828

CASE 1 Mark is a 45 years-old male and is here as a new patient (New patient) to have several lipomas removed.(Chief complaint) He has had these for many years.(HPI: Duration) He has had about 12 removed.(ROS: Integumentary) They get bigger slowly over time. (HPI: Severity) Some of them are tender to touch. (HPI: Quality) They get irritated when he is handling people as a firefighter. (HPI: Modifying factors) PAST MEDICAL HISTORY: None. ALLERGIES: None. MEDICATIONS: None. PAST SURGICAL HISTORY: Nasal surgery, knee surgery. (Past medical history) SOCIAL HISTORY: Cigarettes: None. (Social history) FAMILY HISTORY: He does have a family history of melanoma in his paternal grandfather who died from it. (Family history) PHYSICAL EXAMINATION: On examination, he has subcutaneous masses of his left forearm and two spots of his left posterior arm. That is the biggest of those three. It is about 1.3 cm. He has four on his right upper extremity, two on his lower forearm and two on his posterior arm. He has some of his belly. (Organ: Skin) MEDICAL DECISION MAKING: The patient has multiple lipomas (Diagnosis) which are tender. He would like them removed. With his permission, I have drawn how we would incise the skin over these and about how long the scar would be. There is really no alternative to treatment other than surgery. Some plastic surgeons will do this with liposuction, but I have found that personally the recurrence rate is quite high when I have tried to do it with liposuction, so I generally just excise them. Risks would include infection and bleeding. (Elective major surgery (removal of subcutaneous lipoma has a 90-day global); although provider documents risk of infection and bleeding, this is not above the normal risk associated with a surgery.) We do not know why people get these, so this is something that Mark will have to deal with forever. We will do that here in the office. We will do about three at a time. We are going to start with his left upper extremity. It will be a privilege to take care of Mark. What are the CPT® and ICD-10-CM codes reported?

99201 D17.21 D17.22 D17.1

CASE 5 The patient is a 32 year-old male here for the first time. (New patient.) Chief Complaint: Left knee area is bothersome,(Chief complaint.) painful moderate severity.(HPI: Severity) The patient also notes swelling (HPI: Associated Signs & Symptoms) in the knee area,(HPI: Location) limited ambulation,(HPI: Severity again (not counted twice)) and inability to perform physical activities such as sports or exercises. The patient first noticed symptoms approximately 4 months ago. (HPI: Duration) Problem occurred spontaneously. Problem is sporadic.(HPI: Timing) Patient has been prescribed hydrocodone and meloxicam. Patient has had temporary pain relief with the medications. The meloxicam has caused digestion problems so patient has avoided using it. (HPI: Modifying factors and their affects.) Past Medical History: Patient denies any past medical problems. Surgeries: Patient has undergone surgery on the appendix. Hospitalizations: Patient denies any past hospitalizations that are noteworthy. Medications: Hydrocodone Allergies: Patient denies having allergies. (PFSH: Past Medical History) Family History: Mother: No serious medical problems; Father: No serious medical problems.(PFSH: Family History) Social History: Patient is married. Occupation: Patient is a chef. (PFSH: Social History) Review of Systems: Constitutional: Denies fevers. Denies chills. Denies rapid weight loss. Eyes: Denies vision problems. Ears, Nose, Throat: Denies any infection. Denies loss of hearing. Denies ringing in the ears. Denies dizziness. Denies a sore throat. Denies sinus problems. Cardiovascular: Denies chest pains. Denies an irregular heartbeat. Respiratory: Denies wheezing. Denies coughing. Denies shortness of breath. Gastrointestinal: Denies diarrhea. Denies constipation. Denies indigestion. Denies any blood in stool. Genitourinary: Denies any urine retention problems. Denies frequent urination. Denies blood in the urine. Denies painful urination. Integumentary: Denies any rashes. Denies having any insect bites. Neurological: Denies numbness. Denies tremors. Denies loss of consciousness. Hematologic/Lymphatic: Denies easy bruising. Denies blood clots. Psychiatric: Denies depression. Denies sleep disorders. Denies loss of appetite. (ROS: Complete) Review of Previous Studies: Patient brings an MRI which is reviewed. Large knee effusion. No lateral meniscal tear. No ACL/PCL tear. No collateral fracture. Medial meniscus tear with grade I signal. (Previous studies reviewed used in MDM.) Vitals: Height: 6'0", Weight: 160 Physical Examination: Patient is alert, appropriate, and comfortable. Patient holds a normal gaze. Pupils are round and reactive. (Exam: Eyes) Gait is normal. (Exam: Musculoskeletal) Skin is intact. No rashes, abrasions, contusions, or lacerations. (Exam: Skin)No venous stasis. No varicosities. (Exam: Cardiovascular) Reflexes are normal patellar. No clonus.(Exam: Neuro) Knee: Range of motion is approximately from 5 to 100 degrees. Pain with motion. No localized pain. Negative mechanical findings. There is an effusion. Patella is tracking well. No tenderness. Patient feels pain especially when taking stairs or squatting. Hip: Exam is unremarkable. Normal range of motion, flexion approximately 105 degrees, extension approximately 10 degrees, abduction approximately 25 degrees, adduction approximately 30 degrees, internal rotation approximately 30 degrees, external rotation approximately 30 degrees. (Exam: Musculoskeletal) Neck: Neck is supple. No JVD. (Exam: Neck) Impression: 1. Infective synovitis of the left knee 2. Contracture of the left knee 3. Possible medial meniscal tear of right knee (Uncertain diagnosis) Assessment and Plan: A discussion is held with the patient regarding his condition and possible treatment options. Patient has GI upset. Patient is recommended to take Motrin 400 two to three times a day (Over the counter medication), discussion is held regarding proper use and precautions. Patient is given a prescription for physical therapy.(Physical therapy prescribed) We will obtain an MRI (Additional test ordered) to rule out potential medial meniscus tear. Patient is instructed to follow up with PMD with labs. Patient is referred to Dr. XYZ. Patient may need arthroscopy if patient does have medial meniscus tear and repeat effusion. (Uncertain prognosis on the tear. The patient is sent for additional work-up to determine if there is a tear present.) What are the CPT® and ICD-10-CM codes reported?

99203 M65.162 M24.562

CASE 3 IDENTIFICATION: The patient is a 37 year-old Caucasian lady. CHIEF COMPLAINT: The patient is here today for follow-up (Established patient & established problem.) of lower extremity swelling. (Chief complaint) HISTORY OF PRESENT ILLNESS: A 37 year-old with a history of dyslipidemia and chronic pain. (Past medical history) The patient is here for follow-up of bilateral lower extremity (HPI: Location) swelling. The patient tells me that the swelling responded to hydrochlorothiazide. (HPI: Modifying factor) EXAM: Very pleasant, no acute distress (NAD). VITALS: P: 67, R: 18, Temp 98.6, BP: 130/85. DATA REVIEW: I did review her labs, (Lab reviewed) and echocardiogram. (Echocardiogram review) The patient does have moderate pulmonary hypertension. ASSESSMENT: 1. Bilateral lower extremity swelling: This has resolved with diuretics; this may be secondary to problem #2.(Possibly due to pulmonary hypertension, but not certain, so code separately.) 2. Pulmonary hypertension: Etiology is not clear at this time, will do a work up and possible referral to a pulmonologist. PLAN: I think we will need to evaluate the etiology of the pulmonary hypertension. The patient will be scheduled for a sleep study. What are the CPT® and ICD-10-CM codes reported?

99212 M79.89 I27.20

CASE 6 Established patient Chief complaint: thoracic spine pain PROBLEM LIST: 1. Rheumatoid arthritis, right and left hands. 2. Compression fracture of the thoracic spine T11. 3. Alcoholism. 4. Depression/anxiety. REVIEW OF SYSTEMS: His pain is significantly improved in his thoracic spine. He does have low back pain. He has a history of chronic low back pain. He is still wearing a thoracic support brace. He is going to follow up with Dr. X's office in about six weeks or so. Since I have seen him last he had a small flare of arthritis after his Humira injection. This resolved after 2-3 days. He had pain and stiffness in his hands. Currently he denies any pain and stiffness in his hands. He has one cystic mass on his left hand, second distal pad that is bothersome. CURRENT MEDICATIONS: Vasotec 20mg a day, Folic Acid 1mg a day, Norvasc 5mg a day, Pravachol 40mg a day, Plaquenil 400mg a day, Humira 40mg every other week, Celexa 20mg a day, Klonopin .5mg as needed, aspirin 81mg a day, Ambien 10mg as needed, Hydrocodone as needed. PHYSICAL EXAM: He is alert and oriented in no distress. Gait is unimpaired. He is wearing the thoracic brace. Spine ROM is not assessed. Lungs: Clear. Heart: Rate and rhythm are regular. MUSCULOSKELETAL EXAM: There is generalized swelling of the finger joints without any significant synovitis or tenderness. There is a cystic mass on the pad of his second left finger, which is tender. Remaining joints are without tenderness or synovitis. REVIEW OF DEXA(Dual Energy X-ray Absorptiometry) SCAN: (Performed in office today) There is low bone density with a total T-score of -1.1 of the lumbar spine. Compared to previous it was -0.8. There has been a reduction by 3.6%. T-score of the left femoral neck -1.1, Ward's triangle -2.4, and total T-score is -0.8 compared to previous there has been a 7% reduction from 2005. ASSESSMENT: 1. Seronegative rheumatoid arthritis in both hands. He is doing fairly well. He does have a cystic mass, which seems to be a synovial cyst of the left second digit. He was wondering if he could have this aspirated. 2. Senile osteoporosis and continued care for compression pathologic fracture. He is being treated for osteoporosis because of this. He is tolerating Fosamax well. He is also using Miacalcin nasal spray temporarily to help and it has been effective. PLAN: 1. Continue current therapy. 2. Aspirate the synovial cyst in the left second finger. 3. Follow up in about 6-8 weeks. 4. Repeat labs prior to visit. PROCEDURE NOTE: With sterile technique and Betadine prep, the radial side of the second finger is anesthetized with 1cc 1% Lidocaine for a distal finger block. Then the synovial cyst is punctured and material was expressed under the skin. I injected it with 20mg of Depo-Medrol. He will keep it clean and dry. If it has any signs or symptoms of infection, he will let me know. What are the CPT® and ICD-10-CM codes reported?

99213-25 20612-F1 77080 J1020 M06.041 M06.042 M71.342 M80.08XD

CASE 8 Hospital Admission Chief complaint: Nausea and vomiting, weakness HPI: The patient is a 78 year-old Hispanic female with a history of diabetes, hypertension, and osteoporosis who was just discharged after hospitalization for gastroenteritis three days ago. She went home and was feeling fine, was tolerating regular diet until yesterday when she vomited. She stated she feels nauseated now, feels like she needs to throw up but cannot vomit. Her last bowel movement was yesterday. She stated it was diarrhea and states she has extreme weakness. No melena or hematochezia. No shortness of breath, no chest pain. Medical History: Diabetes mellitus type 2. Hypertension. Osteoporosis. Surgical History: None Medicines: Benadryl 25 mg daily, Diovan 320/25 one daily, calcium 600 daily, vitamin C 500 daily, multivitamin 1 tablet daily, Coreg CR 20 mg daily, Lipitor 20 mg at bedtime, metformin 1000 mg/day. Allergies: MORPHINE Social History: No tobacco, alcohol or drugs. She is a widow. She lives in Marta. She is retired. Family History: Mother deceased after childbirth. Father deceased from asphyxia. ROS: Negative for fever, weight gain, weight loss. Positive for fatigue and malaise. Ears, Nose, Throat: Negative for rhinorrhea. Negative for congestion. Eyes: Negative for vision changes. Pulmonary: Negative for dyspnea. Cardiovascular: Negative for angina. Gastrointestinal: Positive for diarrhea, positive for constipation, intermittent changes between the two. Negative for melena or hematochezia. Neurologic: Negative for headaches. Negative for seizures. Psychiatric: Negative for anxiety. Negative for depression. Integumentary: Positive for rash for which she takes Benadryl. Genitourinary: Negative for dysfunctional bleeding. Negative for dysuria. Objective: Vital signs: Show a temperature max of 98.1, T-current 97.6, pulse 62, respirations 20, blood pressure 168/65. O2 sat 95% on room air. Accu-Chek, 135. Generally: No apparent distress, oriented x 3, pleasant Spanish speaking female. Head, ears, eyes, nose, throat: Normocephalic, atraumatic. Oropharynx is pink and moist. No scleral icterus. Neck: Supple, full range of motion. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. No murmurs, gallops, rubs. Abdomen: Soft, nontender, nondistended. Normal bowel sounds. No hepatosplenomegaly. Negative Murphy's sign. Back: Costovertebral angle tenderness Extremeties: No clubbing, cyanosis or edema. Laboratory Studies. Shows a sodium 125, potassium 3.1, chloride 90, CO2 27, glucose 103, BUN 13, creatinine 0.7, white count 8.3, hemoglobin and hematocrit 12.6, 37.1, platelets 195, 000. Differential shows 76% neutrophils. Amylase 42, CK-MB 1.7, troponin 0.05, CPK 59. PTT 26.9. PT and INR 12.9 and 1.09. UA shows 500 leukocyte esterase, negative nitrite, 15 of ketones, 10 to 25 WBCs. Gallbladder sonogram shows a 1.24 x 1 cm echogenic focus in the gallbladder, possibly representing gallbladder polyp or gallbladder mass. CT abdomen and pelvis shows cholelithiasis, small left pleural effusion, small indeterminate nodules both lung masses, no acute bowel abnormality and sclerotic appearance of right greater trochanter, no free air. Assessment 1. Nausea, vomiting, diarrhea, likely gastroenteritis 2. Cystitis 3. Hypokalemia 4. Hyponatremia 5. Cholelithiasis 6. Diabetes mellitus type 2 7. Hypertension Plan: Will admit patient for IV hydration, add Levaquin 500 mg IV q 24 hours. Will add 20 mg KCl per L to IV fluid. Get a general surgery consult for cholelithiasis. Will check studies, fecal white blood cells, C. diff-toxin and fecal stool culture and sensitivity. What are the CPT® and ICD-10-CM codes reported?

99222 R11.2 R19.7 N30.90 E87.6 E87.1 K80.20 E11.9 Z79.84 I10

CASE 9 Hospital progress note Subjective: Patient is without complaint. She states she feels much better. No vomiting or diarrhea. She did have bowel movement yesterday. No shortness of breath, no chest pain. The patient and daughter were questioned again about her cardiac history. She denies any cardiac history. She has no orthopnea, no dyspnea on exertion, no angina in the past and she has never had any heart problems in the past. Case discussed yesterday with Dr. Williams and I am waiting to find out on her surgery date. Objective: Vital Signs: Shows a T-max of 99.6, T-current 98, pulse 72, respirations 18. Blood pressure 154/65, 02 sat 96% on room air. Accu-checks, 113, 132, 96, 98. General: No apparent distress, oriented x 3, pleasant Spanish-speaking female. Head, Ears, Eyes, Nose, Throat: Normocephalic, atraumatic. Oropharynx pink and moist. Left eye has sclera erythema. Pupils equal, round, and reactive to light accommodation (PERRLA). Laboratory Data: Shows C Diff-toxin negative. Sodium 129, potassium 3.4, chloride 96, CO2 27, glucose 72, BUN 12, creatinine 0.6. Urine culture positive for E. coli, sensitive to Levaquin. Assessment: 1. Cholelithiasis 2. Cystitis 3. Conjunctivitis 4. Hyponatremia 5. Hypokalemia 6. Diabetes mellitus type 2 7. Hypertension If the patient is not to go to surgery today, will feed the patient and likely discharge her if she tolerates regular diet. Will add Norvasc 5 mg p.o. daily. Also pleural effusion, small. Will repeat a chest-x-ray PA and lateral this morning to evaluate that. What are the CPT® and ICD-10-CM codes reported?

99232 K80.20 N30.90 H10.9 E87.1 E87.6 E11.6 I10

CASE 10 Discharge summary Hospital course: The patient was hospitalized two days ago with nausea and vomiting. She had an uneventful hospital course. She was diagnosed with cholelithiasis. General surgery was consulted. Dr. Williams thought this was perhaps causing her upper GI symptoms. She was scheduled for surgery on Monday. She was tolerating a regular diet. Her nausea and vomiting resolved and she desired to be dismissed home. She was found to have a bladder infection. She was started on Levaquin and she also had left eye conjunctivitis and she was given Clloxan eye ointment for that. Discharge Diagnoses: 1. Cholelithiasis 2. Cystitis 3. Conjunctivitis 4. Hyponatremia 5. Diabetes mellitus type 2 6. Hypertension Discharge Medications: 1. Levaquin 500 mg p.o. daily x2 days 2. Ciloxan ointment, apply b.i.d.to left eye x 4 days/ 3. Zofran 4 mg p.o. q. 4 hours p.r.n. nausea, vomiting #20 4. Benadryl 25 mg p.o. daily p.r.n. rash 5. Diovan 320 p.o. daily 6. Calcium 600 mg p.o. daily 7. Vitamin C 500 mg p.o. daily. 9. Metformin 1000 mg p..o. daily 10. Lipitor 20 mg p.o. at bedtime 11. Coreg CR 20 mg p.o. daily. Discharge Diet: Cardiac Activities: ad lib Discharge Instructions: Patient to be NPO after midnight Sunday. Dismiss: Home Condition: Good Follow-up: Follow-up with me in 1 week. Follow-up on Monday morning for cholecystectomy. NPO after midnight on Sunday. What are the CPT® and ICD-10-CM codes reported?

99238 K80.20 N30.90 H10.9 E87.1 E11.9 Z79.84 I10

CASE 7 XYZ Nursing Home Subjective: The patient appears to be a little more altered than normal today. He is in some obvious discomfort. However, he is not able to communicate due to his mental status. Patient does appear fairly anxious. Physical Exam: Glucoses have been within normal limits. Patient has had poor p.o. intake, however, over the last 2-3 days. Temperature is 97, pulse is 79, respirations 20, blood pressure 152/92, and oxygen saturation 97% on room air. Patient can be aroused. Extraocular movements are intact. Oral pharynx is clear. Lungs are clear to auscultation bilaterally. Heart has a regular rate and rhythm. Abdomen is nontender and nondistended. Patient is able to move all extremities. He does have some mild pain over the apex of his right shoulder and bruising over the anterior lateral rib cage on the right side over approximately T8 to T10. No crepitus is noted. Patient indicates he hurts everywhere. Ancillary studies: A.M. labs - none new this morning. X-ray shows no evidence of fracture with definitive arthritis. Patient has chronic distention of bowels. This is always atypical exam. Telemetry shows no significant new arrhythmias. Assessment & Plan: 1. Patient is an 84 year-old Caucasian male who presented after a fall with rib contusion, right shoulder pain and uncontrolled pain since. He has been on Tramadol. However, I believe this is making him more altered. Thus, we will back off on medications and see if he comes back more to himself. We may try a different medication at a low dose later today if patient's mental status improves significantly. We will have patient out of bed three times a day. Physical therapy is working with the patient for significant deconditioning. 2. Patient with elevated blood pressures upon admission and still running a little bit high. Cardizem has been added to the medication regimen recently. We will follow this and see what it does for his blood pressure in the long run. He is in no immediate danger currently. 3. Very advanced dementia, will follow, continue on home medications. 4. Coronary artery disease and congestive heart failure. These appear stable at this time. 5. History of atrial fibrillation, sounds to be in regular rhythm currently and appears to be doing well on telemetry monitor. Again, Cardizem has been added for better control and blood pressure control. 6. Type 2 diabetes mellitus. Glycemic control has been good. However, patient has had poor p.o. intake over the last 2-3 days, which may be due to pain. Thus, we will hold glipizide for now to prevent hypoglycemia. 7. We will follow the patient closely and adjust medications as necessary. What are the CPT® and ICD-10-CM codes reported?

99309 S20.211A M25.511 R03.0 F03.90 I25.10 I50.9 I48.91 E11.9 Z79.84

CASE 4 AGE: 33 year-old - Established patient VITAL SIGNS: TEMPERATURE: 98.9°F Tympanic, PULSE: 97 Right Radial, Regular, BP: 114/70 Right Arm Sitting, PULSE OXIMETRY: 98% , WEIGHT: 161 lbs. CURRENT ALLERGY LIST: LORTAB CURRENT MEDICATION LIST: LUNESTA ORAL TABLET 3 MG, 1 Every Day At Bedtime, As Needed PROZAC ORAL CAPSULE CONVENTIONAL 40 MG, 1 Every Day LEVOTHYROXINE SODIUM ORAL TABLET 100 MCG, 1 Every Day for thyroid MELOXICAM ORAL TABLET 15 MG, 1 Every Day for joint pain IMITREX ORAL TABLET 100 MG, 1 tab po as directed , can repeat after 2 hours for migraines, max 2 per day PHENERGAN 25 MG, 1 Every 4-6 Hours, As Needed for nausea CHIEF COMPLAINT: Here for a comprehensive annual physical and pelvic examination. (Patient is seen for a routine Pap smear and comprehensive physical exam. This will be a preventive visit.) HISTORY OF PRESENT ILLNESS: Pt here for routine pap and physical. Pt reports episode of syncope two weeks ago. Pt went to ER and had EKG, CXR and labs and says she was sent home and per her report everything was normal. She denies episodes since that time. She does occasionally have mild mid-epigastric discomfort but no breathing problems or light-headedness. Good compliance with her thyroid meds. (Discussion of meds for thyroid. This is not sufficient enough to bill a problem visit along with the preventive visit.) PAST MEDICAL HISTORY: Depression. FAMILY HISTORY: no cancer or heart disease, mother has hypertension. SOCIAL HISTORY: TOBACCO USE: Currently smokes 1 1/2 PPD, has smoked for 15 to 20 years. REVIEW OF SYSTEMS: Patient denies any symptoms in all systems except for HPI. PHYSICAL EXAM: (Comprehensive physical exam.) CONSTITUTIONAL: Well developed, well-nourished individual in no acute distress. EYES: Conjunctivae appear normal. PERLA ENMT: Tympanic membranes shiny without retraction. Canals unremarkable. No abnormality of sinuses or nasal airways. Normal oropharynx. NECK: There are no enlarged lymph nodes in the neck, no enlargement, tenderness, or mass in the thyroid noted. RESPIRATORY: Clear to auscultation and percussion. Normal respiratory effort. No fremitus. CARDIOVASCULAR: Regular rate and rhythm. Normal femoral pulses bilaterally without bruits. Normal pedal pulses bilaterally. No edema. CHEST/BREAST: Breasts normal to inspection with no deformity, no breast tenderness or masses.(Breast exam.) GI: Soft, non-tender, without masses, hernias or bruits. Bowel sounds are active in all 4 quadrants. GU: EXTERNAL/VAGINAL: Normal in appearance with good hair distribution. No vulvar irritation or discharge. Normal clitoris and labia. Mucosa clear without lesions. Pelvic support normal.(Thin prep Pap smear collection.) CERVIX: The cervix is clear, firm and closed. No visible lesions. No abnormal discharge. Specimens taken from the cervix for thin prep pap smear. UTERUS: Uterus non-tender and of normal size, shape and consistency. Position and mobility are normal.(Pelvic exam.) ADNEXA/PARAMETRIA: No masses or tenderness noted. LYMPHATICS: No lymphadenopathy in the neck, axillae, or groin. MUSCULOSKELETAL EXAM: Gait intact. No kyphosis, lordosis, or tenderness. Full range of motion. Normal rotation. No instability. EXTREMITIES: BILATERAL LOWER: No misalignment or tenderness. Full range of motion. Normal stability, strength and tone. SKIN: Warm, dry, no diaphoresis, no significant lesions, irritation, rashes or ulcers. NEUROLOGIC: CNs II-XII grossly intact. PSYCHIATRIC: Mood and affect appropriate. LABS/RADIOLOGY/TESTS: The following labs/radiology/tests results were discussed with the patient: Alb, Bili, Ca, Cl, Cr, Glu, Alk Phos, K, Na, SGOT, BUN, Lipid profile, CBC, TSH, PAP smear. ASSESSMENT/PLAN: UNSPECIFIED ACQUIRED HYPOTHYROIDISM What are the CPT® and ICD-10-CM codes reported?

99395 Z00.00 Z01.419 E03.9