(Solved): I NEED THE ICD 10 CM CODES FOR THIS SCENARIO:Primary diagnosis code Secondary diagnosis code Second ...

Scenario 8 AMB General Adult Clinic Note History and Encounter Details: Patient Demographics and Check In Details: Patient arrived at 08:54. The appointment was scheduled at 09:10. Payer is Superior. Patient is established. Chief Complaint: LAB RESULTS... Vital Signs: Jul-10-2018 08:57:00 Temp C:36.5 Temp F: 97.8 HR:'72 RR: 18 BP: $129/85$ Ht cm: 162.56 Wt kg: 58 Wt lbs: 127.86 BSA: 1.61 BMI: 21.9 HPI + Past History: Patient is a 52 year old fermale patient. The patient has the following Problems: Chronic Problem: Benign hypertension; Elevated serum alkaline phosphatase level; Hypercholesterolemia; Hyperlipidemia; Hyperlipidemia due to type 2 diabetes mellitus; Low vitamin D level; Screening; Transaminitis; Type 2 diabetes mellitus with hyperglycemia, without long-term current use of insulin; Uncontrolled diabetes mellitus with hyperglycemia Patient here to f/u on labs and chronic conditions. Reviewed labs and discussed with patient, verbalized understanding. DM a1c 12.6 (2017)--> $12.4(6/18)$ on janumet reports adherence FBS 252, 216 PP 229, 210 EYe exam neg retinopathy (6/18) neg proteinuria ( $7/5/18)$ Diabetes Medications: 1. Janumet $50\mathrm{mg}?500\mathrm{mg}$ oral tablet: $1\mathrm{tab}$ (s) orally 2 times a day $\times 90$ days HTn bp at goal hyperlipidemia LDL 124 goal $<100$ Social History / Screenings: Patient does not use alcohol. Patient does not use recreational drugs. Provider start time:: 09:17 Abuse Screening: Are you currently in any relationships that make you feel unsafe?: no (1) Smoking Status: - Have you ever smoked? No Review of Systems: Review of Systems: - General: negative: anorexia, chills, fever, malaise/fatigue, weight loss - Respiratory: negative: cough, dyspnea, hemoptysis, pleuritic chest pain, wheezing - Cardiovascular: negative: chest pain, claudication, lower extremity swelling, orthopnea, palpitation - Neurological: negative: confusion/memory loss, dizziness, headache, numbness, weakness - Psychiatric: negative: anxiety, depression, hallucinations, insomnia, mood problems OMRI Allergies: ALLERGIES: - No Known Allergies: Outpatient Medication Review: *Patient Currently Takes Medications as of Jul-10-2018 08:59 documented in Structured Notes aspirin $81\mathrm{mg}$ oral tablet: Review Status: Verified, $1\mathrm{tab}(\mathrm{s})$ orally once a day for high blood pressure, Quantity: 90, Refills: 1, Submitted By: Carvalho, Clarissa Janumet $50$ mg-500 mg oral tablet: Review Status: Verified, 1 tab(s) orally 2 times a day $\times 90$ days, Quantity: 180, Refills: None, Submitted By: Carvalho, Clarissa carvedisol $6.25\mathrm{mg}$ oral tablet: Review Status: Verified, 1 tab(s) orally 2 times a day x 90 days, Quantity: 180, Refills: 3, Submitted By: Carvalho, Clarissa losartan-hydrochlorothiazide $50\mathrm{mg}?12.5\mathrm{mg}$ oral tablet: Review Status: Verified, 1 tab(s) orally once a day $x90$ days, Quantity: 90, Refills: 2, Submitted By: Carvalho, Clarissa atorvastatin $10\mathrm{mg}$ oral tablet: Review Status: Verified, 1 tab(s) orally once a day (at bedtime) $x$ 90 days -for dyslipidemia, Quantity: 90, Refills: 1, Submitted By: Carvalho, Clarissa ergocalciferol 50,000 intl units $(1.25\mathrm{mg})$ oral capsule: Review Status: Verified, $1\mathrm{cap}(\mathrm{s})$ orally once a week for low vit d, Quantity: 9, Refills: None, Submitted By: Vasquez, Veronica M Physical Examination: - General Appearance Comments - Respiratory Comments - Cardiovascular Comments - Edema Or Varicosities Comments - Musculoskeletal Comments - Neurological Comments - Psychiatric Comments Labs/Radiology: Lab Results: Chemistry Trend: Jul-05-2018 09:07 Sodium Serum: 137 Potassium Serum: 3.8 no acute distress. Normal respiratory effort, clear to auscultation. Regular sinus rhythm, S1 normal, S2 normal. No murmur, rub or gallop. no edema Normal gait and station. Oriented to person, place and time. Normal mood and affect. Chloride Serum: 103 Carbon Dioxide Total Serum: 28 Anion Gap: 6 Glucose Serum: +212 Interpretation: The following guidelines were established by the American Diabetes Association and placed in effect 03-15-2007: FPG $<100\mathrm{mg}/\mathrm{dL}=$ Normal fasting glucose FPG $100?125\mathrm{mg}/\mathrm{dL}=$ Impaired fasting glucose FPG >= $126\mathrm{mg}/\mathrm{dL}=$ provisional diagnosis of diabetes Sulfasalazine or sulfapyridine administration prior to venipuncture may result in falsely depressed or falsely elevated results, respectively.) Blood Urea Nitrogen (BUN) Serum: 20 Creatinine Serum: 0.57 Calcium Serum: 8.7 Protein Total Serum: 6.9 Albumin Serum: 3.4 Bilirubin Total Serum: 0.6 Alkaline Phosphatase Serum: $?129$ ASTISGOT Serum: 18 Interpretation: Sulfasalazine or sulfapyridine administration prior to venipuncture may result in falsely depressed results.) ALT/SGPT Serum: 25 Interpretation: Sulfasalazine or sulfapyridine administration prior to venipuncture may result in falsely depressed results.) Thyroid Stimulating Hormone: 1.519 (Interpretation: 0.00-0.12 $\mathrm{microlU}/\mathrm{mL}=$ Adult hyperthyroid range $>6.12\mathrm{microlU}/\mathrm{mL}=$ Adult hypothyroid range TSH results can be falsely depressed on a patient that has undergone procedures with fluorescent dye. Delay in testing to allow for clearance is recommended.) Glomerular Filtration Rate Estimated: $>60$ Cholesterol Serum: 185 Interpretation: Recommendations of the Treatment Panel III of the National Cholesterol Education Program for classification of patients: TOTAL CHOLESTEROL (mg/dL) CHD RISK CLASSIFICATION Child $<\overline{170}?\dots$ Desirable 170-199 ... Borderline High $>=200\dots$... High Jul-05-2018 09:07 White Blood Cell Count: 5.47 RBC Count: 4.47 Hemoglobin: 14.3 Hematocrit: 41.1 MCV: $91.9$ MCH: 32.0 MCHC: $?34.8$ RDW: 11.8 Mean Platelet Volume: 11.4 Platelet Count: 202 Urine Studies: Jul-05-2018 09:07 Creatinine, Random Urine: 112.7 Microalbumin/Creatinine Ratio, Urine: 0.026 Microalbumin,Random Urine: $?2.9$ Medical Decision Making: Problem/Assessment Plan: 1: Hyperlipidemia due to type 2 diabetes mellitus - ICD10 E11.69 LDL goal < 100 increase atorvastatin to $20\mathrm{mg}$ at hs monitor 2: Benign hypertension - ICD10 I10 bp at goal Continue bp meds 3: Transaminitis - ICD10 R74.0 LFT wnl 4: Type 2 diabetes mellitus with hyperglycemia, with long-term current use of insulin - ICD10 E11.65 a1c not at goal add lantus with titration Continue janumet continue diet, exercise and lifestyle modifications. $\mathrm{dm}$ education Blood sugar monitoring fasting and $2\mathrm{hrs}$ after dinner Prescriptions List: - Janumet $50\mathrm{mg}?500\mathrm{mg}$ oral tablet: $\mathrm{Rx},1$ tab(s) orally 2 times a day $\times 90$ days, Status: Active, Refills: 2, None - Needles: B-D Ultra Fine short pen needles: Rx, Use as directed once a day for DM, Status: Active, Refills: 11, None - Lantus Solostar Pen 100 units/mL subcutaneous solution: $\mathrm{Rx},15$ unit(s) subcutaneous once a day (at bedtime) $\times 90$ days titrate Lantus by adding 2 units every 3 days for FBS> 120, Status: Active, Refills: 2, None - atorvastatin $20\mathrm{mg}$ oral tablet: $\mathrm{Rx},1\mathrm{tab}(\mathrm{s})$ orally once a day (at bedtime) $\times 90$ days, Status: Active, Refills: 2, None POC/Staff Orders/lnterventions: Nursing Staff Orders: $\mathrm{dm}$ education Blood sugar monitoring fasting and $2\mathrm{hrs}$ after dinner give her BS logs for daily monitoring exit care on $\mathrm{dm}$ bring all meds to visit f/u in 2-3 weeks with BS logs FIT Test mammogram. Dismissal Information: - Spoken Preferred Language: English. - Preferred Language: English. Refill Protocol: REFILL PER PROTOCOL: "Designated staff may refill medications per protocol if applicable". Visit Type: Visit Type: - Provider end time: $09:34$ Chronic Problem: Type 2 diabetes mellitus with hyperglycemia, with long-term current use of insulin (E11.65): Status: Active, ICD-9: 250.00, ICD-10: E11.65 Hyperlipidemia due to type 2 diabetes mellitus (E11.69): Status: Active, ICD-9: 250.80, ICD10: E11.69 Transaminitis (R74.0): Status: Active, ICD-9: 790.4, ICD-10: R74.0 Electronic Signatures: Dr. Fam (MD) (Signed MM/DDNYYY 10:53) Authored: History, Social History/Risk Assessments, Review of Systems, OMR/ Allergies, Physical Exam, Labs/Radiology, Medical Decision Making, Immunizations and Wellness Manager, POC/Staff Orders/Interventions, Refill Protocol, Closing