What are the CPT codes for the

What are the CPT codes for the scenario attached? Global Care Medical Center 100 Main St, Alfred NY 14802 (607) 555-1234 PHYSICIAN’S OFFICE ENCOUNTER FORM EIN: 12-345678 BCBS PIN: GC2222 BCBS GRP: 1234-P MCD PIN: GCMC1234 MEDICARE UPIN: GC1111 PATIENT INFORMATION: NAME: MILLER, Edward W. PATIENT NUMBER: POCase022 ADDRESS: 5842 Church Street ADMISSION DATE & TIME: 08-17-YYYY CITY: Alfred PRIMARY INSURANCE PLAN: Medicare STATE: NY PRIMARY INSURANCE PLAN ID #: 088028326A ZIP CODE: 14802 SECONDARY INSURANCE PLAN: TELEPHONE: 607-587-2441 SECONDARY INSURANCE PLAN ID #: GENDER: Male OCCUPATION: Retired DATE OF BIRTH: 01-15-1921 NAME OF EMPLOYER: DIAGNOSIS INFORMATION Diagnosis Code Diagnosis Code 1. 5. 2. 6. 3. 7. 4. 8. PROCEDURE INFORMATION Description of Procedure or Service Date Code Charge 1. 2. 3. 4. 5. SPECIAL NOTES: Global Care Medical Center 100 Main St, Alfred NY 14802 (607) 555-1234 PHYSICIAN OFFICE RECORD PATIENT NAME: MILLER, Edward W. PATIENT NUMBER: POCase022 DATE OF SERVICE: 08-17-YYYY DATE OF BIRTH 01-15-1921 NURSING DOCUMENTATION: MEDICATIONS ALLERGIES/REACTIONS: None CURRENT MEDICATIONS: Dilantin, Lasix, captopril, Beclomethasone inhaler, albuterol, and Atrovent. BP: 160/80 P: 80 R: 18 T: WT: 121 HEENT: Within Normal Limits PMH: Insulin dependent diabetic, chronic airway obstruction, and seizure disorder. NOTES: There are no acute medical problems or complaints at this time. SIGNATURE OF PRIMARY CARE NURSE: Mary Kay Place, R.N. PHYSICIAN DOCUMENTATION: Notes: Mr. Miller is 81-year-old white male with the following problems: Insulin dependent diabetic. Chronic airway obstruction. Seizure disorder. Mr. Miller was last seen in May of this year at that time he had an acute bronchitis and was treated for it and has done quite well since. Today he is alert, oriented and quite pleasant. There are no acute medical problems or complaints at this time. His last labs were done the 10th of this month showing a glycosylated hemoglobin of 7.9, creatinine 1.2 and potassium 4.5. Last Dilantin level was done in May which was 6.7, which is below the therapeutic range. However on the 13th of May which was two weeks before that Dilantin level he a level of 22.7 which was elevated. At the present time he is taking Dilantin 200 mg in the morning and 100 mg at bedtime. His other medications at this time consist of Lasix 20 mg daily, captopril 6.25 mg b.i.d., the Dilantin as previously stated. He takes NPH insulin, 22 units in the morning and 14 units at bedtime. He takes 8 units of regular insulin in the morning and 4 units at bedtime. He was also on Beclomethasone inhaler, albuterol and Atrovent. Upon discharge from the outpatient clinic this morning, I have advised him that I am ordering a combivent, which is a combination of Albuterol and Atrovent. It will be an all-in-one inhaler. So he will be aware of that. His vital statistics this morning show him to be standing 63 inches tall. He weighs 121 pounds. His blood pressure 160/80. Pulse 80. Respirations 18. His HEENT is within normal limits. He has several teeth missing in both upper and lower jaw. No cute abnormalities. His lungs were clear to A&P with some fine bibasilar wheezes. His heart had a regular rate and rhythm with no murmur, rubs or ectopic beats noted. His abdomen was flat, nontender. No organomegaly and bowel sounds were within normal limits. The extremities showed no edema, no lesions and no problems with sensation. There were good pedal pulses throughout. IMPRESSION: A well checkup today. He appears to have good control now of his diabetes based on the glycosylated hemoglobin on the 10th of this month. However I will have the patient to return in four months. I will renew all his medications and prior to his next visit repeat the fasting labs including liver function lipids and Dilantin level as well as CBC. I will check also on his last appointments with ophthalmology and podiatry and if not will have consults with them to evaluate him as a diabetic, to put him on their list for routine diabetic ophthalmology and podiatry care. Again, I will follow him in four months time. Total time spent with the patient was 35 minutes. SIGNATURE OF PROVIDER: H.W. Pocket, M.D. DD: 08-17-YYYY DT: 08-19-YYYY H.W. Pocket, M.D. Global Care Medical Center 100 Main St, Alfred NY 14802 (607) 555-1234 LABORATORY DATA PATIENT NAME: MILLER, Edward W. PATIENT NUMBER: POCase022 LOCATION: PO PROVIDER: H.W. Pocket, M.D. SPECIMEN COLLECTED: 08-10-YYYY SPECIMEN RECEIVED: Blood TEST R ESULT F LAG R EFERENCE Creatinine 1.2 **H** ≤ 1.0 mg/dL Potassium 4.5 3.5-5.1 mmol/L HbA1c 7.9 **H** 4-5.9% mmol/L ***End of Report*** SCIENCE HEALTH SCIENCE NURSING MC 285

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