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Patient Information: Date of service: 4/1/xx Location: Shoreline Family Practice Patient Name: Andrew Markey Age: 75 Provider: Dr. Kirsten Conway Chief Complaint: Visit to monitor hypertension and asthma. Complaining of increased shortness of breath (SOB). Habits: None Assessment: Asthma, acute exacerbation, and hypertension. Treatment regimen: Use supplemental oxygen PRN. Questions to Answer: Answer questions a-i to the best of your ability (only your answers): a. What symptom did the patient report in the chief complaint? b. What two conditions are stated in the assessment? c. Is the symptom identified integral to one of the conditions noted in the assessment? Yes or No? d. Should you code the symptom along with the diagnosis(es) noted under the assessment? Yes or No? e. For the treatment regimen, what does it note? f. What is the principal diagnosis? g. What is the secondary diagnosis? h. You have identified two codes for this case. Review your answers to determine sequencing: a. What code is the principal diagnosis (sequenced first)? b. What code is for the second condition?
SCIENCE
HEALTH SCIENCE
NURSING

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