Question

Jenna Ward is a 19-year-old female who presents to the clinic with a chief complaint of 2-day history of burning with urination and vaginal discharge. The discharge is foul smelling. She has tried OTC vaginal treatment without improvement. She has been sexually active with several partners. She is G1, P0, A1. She takes oral contraceptives and menses are regular. She denies any cramping, abdominal pain, or unusual vaginal bleeding. No fever or chills. No routine medications. NKDA.

• Past Medical History: Appendectomy age 16

• Family History: M 32 A&W F 33 IDDM, B 22 asthma

• Smokes ½ PPD, denies alcohol or drug use

• She is 5’4” in height and weighs 137 lbs. Her blood pressure is 120/62, P 76. NAD, afebrile, abdomen soft, +BS, tender in suprapubic area. GU: external genitalia WNL with thick white vaginal discharge noted. No bleeding noted, Cervix pink, no CMT, GC & Chlamydia cultures taken, wet mount obtained, PAP smear performed, bimanual examination WNL no adnexal masses or tenderness.

Labs: UA 20-30 WBCs per HPF/C&S sent, wet mount: + whiff test, + clue cells

1. What are the potential ICD-10 codes in this case?

2. How can the NP determine if this patient is a new patient versus an established patient at the clinic?

3. What components of care will be used for reimbursement decisions for Ms. Ward?

4. What type of physical examination level best fits what was performed on Ms. Ward?

5. If you were coding the visit for Ms. Ward, how would you determine what decision-making level you would choose? Provide your rationale, and be specific.

Answer 1

POTENTIAL ICD-10 CODES

Answer

N76.0 - Acute vaginitis

Jenna Ward is a 19-year-old female who presents to the clinic with a chief complaint of 2-day history of burning with urination and vaginal discharge and the vaginal discharge foul smells

Hence Potential ICD codes for the Ms Ward N76.0

NEW PATIENT VERSUS AN ESTABLISHED PATIENT AT THE CLINIC

Answer

There is difference exists between the new patient and established patient they are

New patients are the one who have not received any professional services within the previous 3 years including any face-to-face services or other Evaluation and Management (E/M) service (e.g., surgical procedure) from the same physician or physician group practice (same physician speciality and subspecialty)

Established patients are the one who has received any professional services within the previous three years including face-to-face or other E/M service services (e.g., surgical procedure) from this provider or another provider (same speciality or subspecialty) in the same group practice

Nurse practitioner can check previous health records for the past three years to determine whether patient is new or established.

COMPONENTS OF CARE ARE

Answer

Physician services, preventive services, Laboratory test, X- Ray are the components of care for the reimbursement decisions for Ms. Ward

PHYSICAL EXAMINATION level best fits Ms. Ward

Answer

Inspection: Foul smelling vaginal discharge

Palpation: Tender suprapubic area

LEVELS OF MEDICAL CODING DECISION MAKING

Answer: Straight forward decision making

In the medical decision making in the evaluation and management rooted in the complexity of the patient’s problem(s) addressed during an encounter. Reviews three areas in each encounter and the physician assigned a point level:

The number of diagnoses and/or treatment options

The amount and/or complexity of data ordered/reviewed

The risk of complications/morbidity/mortality

Number of diagnoses or management options	Amount and/or complexity of data to be reviewed	Risk of complications and/or morbidity or mortality	Level of Complexity of Medical Decision-Making
Minimal	Minimal or None	Minimal	STRAIGHTFORWARD
Limited	Limited	Low	LOW COMPLEXITY
Multiple	Moderate	Moderate	MODERATE COMPLEXITY
Extensive	Extensive	High	HIGH COMPLEXITY

In coding the visit of Mr. Ward Straight forward medical decision making is used as

There is minimal diagnosis

Complexities of data ordered are also limited

Risk of complication and mortality and morbidity are minimal hence it is straight forward decision making level is used