Week 4 Assignment 1: Coding Nursing homework help

Week 4 Assignment 1: Coding Nursing homework help

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Instructions

The purpose of this assignment is to practice evaluating patient encounter notes to identify appropriate Current Procedural Terminology (CPT) codes to submit for billing. This is an important skill to master as an NP.

In this assignment, you are provided with three patient SOAP notes from an encounter with an NP. Using the Required Readings and Required Resources, identify the appropriate code (i.e., 99211, 99212, 99213, etc.) that should have been billed for the visit. In addition, provide detailed rationale on how you came to this decision. Please use the Patient Billing Template (Word).

Patient 1 SOAP note (Word)

Patient 2 SOAP note (Word)

Patient 3 SOAP note (Word) 

NU668 Week 4 Assignment 1: Coding

SOAP Note Billing 3

Source: MT (self) and facility staff

Reliability: good

MT is an 88-year old white male established patient, who has been in the assisted living facility for the past 2 years. He was living with his oldest son and his family for about 15 years. He said his son kept all his pension and social security money and only gave him $50 every month. He said he finally asked his doctor to help him get a referral for social services when he was hospitalized for a fall incident with no complications or sequela.

He is being seen today for his monthly follow-up visit. He said he feels fine except that he started to have on and off loose stools in the past two weeks. The facility staff put him on diapers to prevent him from soiling his pants.

Subjective: Chief Complaint: Diarrhea

Onset of diarrhea 2 weeks ago. Loose watery brown stools about 2-3 times a day but not every day. Denies blood or mucus in his stool. Denies abdominal pain or cramping. MT said he gets an “accident” sometimes and soils his pants. He said he cannot get to the bathroom on time to have a bowel movement. He said he cannot walk fast enough. Denies urinary incontinence. Denies having eaten any exotic or rotten food. He had not been out to eat in the restaurant. Denies having any antibiotics in the past 2 weeks. Facility staff denies having any gastroenteritis cases in the past two weeks. Denies fever, nausea or vomiting. Denies contact with anyone with same symptoms and denies recent travel. He said he did not take any OTC treatment.

ROS: Denies fever, fatigue or chills; Respiratory: Denies cough; Cardiovascular: Denies palpitations; GI: Denies nausea or vomiting, abdominal pain; Reported diarrhea on and off for the past 2 weeks. GU: Denies urinary frequency, urgency or dysuria

Allergies: No Known Allergies

Current medications: Donepezil 5 mg at HS (started 4 weeks ago with previous follow up visit). Vitamin D3 once daily, Vitamin B Complex once daily, Alendronate 70 mg once weekly

Medical History: Alzheimer’s Dementia; Osteoporosis

Surgical History: Inguinal hernia repair, Cataract surgery with lens implant

Social History: Lives at the assisted living facility. He was married once. His wife died about 17 years ago. He has five children.

Smoking: Never smoked; Alcohol: Denies alcohol use; Coffee: 4 cups a day

Family History: Mother died at age 93 from old age; Father died at age 48 from Malaria complications.

Vital signs: BP 108/72 mmHg Temp: 98.4 F HR: 78 bpm RR: 18 bpm

Height: 70 inches

Weight: 150 pounds

Objective:

Physical Examination: Alert awake and oriented to person, place and situation; well nourished; Pharynx: Buccal mucosa is moist, no erythema or edema; Respiratory: Lungs clear to auscultation with no adventitious lung sounds; Cardiovascular: Heart rate regular, with no murmurs; Abdomen soft, non-distended, with normal bowel sounds on all four quadrants; no tenderness, no rigidity, no rebound tenderness, no guarding; No CVA; Skin: warm, dry and intact with good turgor. Walks with a cane.

MT is appropriately dressed and well groomed. He has good eye contact and is cooperative. Mood is euthymic with full range affect. He knows the month and the year but does not remember the exact date and day of the week. Speech, language and responses are normal. Immediate recall is 3/3 and delayed memory recall is 1/3. Serial 7’s counting backwards from 100 is accurate. Spelling WORLD backwards is correct. Judgment and insight is good. Perceptual disturbances such as hallucinations and delusions are not observed. MMSE = 26/30

Clock Drawing: Correctly drew an analogue clock with minute and hour hands at 2:45

Assessment: Mild Neurocognitive Disorder due to Alzheimer’s Dementia

Drug-Induced Diarrhea

The most common side effects of donepezil are nausea, and diarrhea. The prevalence increases with higher doses. The side effects are usually transient and for most patients, the side effects resolve in 2-3 weeks (Rosenblatt, Gao, Mackell, & Richardson, 2010).

Differential Diagnosis

1.

Infectious diarrhea is caused by enteric pathogens such as bacteria, viruses and parasites. Common pathogens are Vibrio cholerae, Clostridium difficile, Shigella, and Escherichia coli. Examples of parasites are Giardia lamblia and Entamoeba histolytica (Hodges & Gill, 2010). Although the history and pattern of diarrhea appears to be drug-induced diarrhea, infectious diarrhea still needs to be ruled out (Hodges & Gill, 2010).


2.
Gastroenteritis is a viral infection of the intestines that usually causes watery diarrhea, abdominal cramps, nausea or vomiting. Sometimes it is accompanied by fever. Many different viruses cause viral gastroenteritis such as rotavirus and norovirus. Most viral gastroenteritis is self-limiting and does not usually last for over 2 weeks (““Stomach Flu”,” n.d.).


3.
Functional Diarrhea is chronic diarrhea without a known cause. It is also classified as a functional gastrointestinal disorder (FGD). The Rome III diagnostic criteria for FGD is a change in stool consistency occurring in at least the last 3 months with onset at least 6 months prior to diagnosis. Functional diarrhea is different than Irritable Bowel Syndrome – diarrhea type (IBS-D) due to a lack of abdominal pain that is present in IBS-D (Bolen, 2017). MT has diarrhea on and off for the past 2 weeks.

Plan: Discontinue Donepezil

Labs: Stool C & S; O & P; CBC

Facility staff to report worsening diarrhea

Patient Education: Rehydration therapy

Follow up in 1-2 weeks or sooner as needed. Follow up when lab results are back.

Referral: None as of this time

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