PROC edure code(s) along with anymodifier(s), if appropriate

PROC edure code(s) along with anymodifier(s), if appropriate. FAMILY DOCTORS ASSOCIATES 123 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234 PATIENT: WITZKE, REBECCA ACCOUNT/EHR #: WITZRE001 This patient is a 34-year-old Caucasian female who presents complaining of headaches. HISTORY OF PRESENT ILLNESS: Patient describes her current headaches as happening every day in midafternoon for the past month. The pain is steady, nonpulsatile, and starts in the occipital region with bilateral radiation to the frontal area. There is no associated aura or photophobia. She is not awakened from sleep with the headaches, and she does not wake up in the morning with a headache. Tylenol lessens the discomfort “sometimes.” When asked if there were any other complaints the patient wishes to discuss, she mentions significant stress at home regarding her 11-year-old son. Her concern centers on continued problems with discipline. “He just won’t listen to me anymore—he’s always beating up on his little brother and getting into fights at school. His grades have really dropped, and he might even be held back this year. I just don’t know what to do.” In reviewing the patient’s chart I note she has been in to our office seven times over the past year. SOCIAL HISTORY: Patient is a college graduate who works part-time as a nursery school teacher. She and her husband, an accountant, have two sons, ages 11 and 6. Further discussion reveals that the patient’s husband has become increasingly controlling over the past few years. In fact, he often calls home up to 10 times per day, making sure she comes home right after work or appointments and stays at home until he returns from work. Patient then discloses that he grabbed her around the neck once. “But it was only once . . . and that was a few weeks ago. It was probably my fault, because dinner wasn’t ready when he got home, and he becomes kind of hypoglycemic.” The patient also states her husband shoved her a few months ago in the kitchen during a dispute over how she has been handling their son. The following day she went to the ED after work. X-rays of her lower extremities showed no fractures, but significant swelling persisted in her knees for a few weeks. Patient reassured me that she feels safe going back to her home, and that she, in fact, does not want to leave. PERSONAL MEDICAL HISTORY: Hypothyroidism and headaches MEDICATIONS: Synthroid 125 mcg each day, Tylenol 650 mg two or three times a day VITAL SIGNS: Temp 98.1; BP 135/85; pulse 80; respiration 20; weight 145 lb; height 5 feet 3 inches GENERAL: Her physical exam is unremarkable with normal vital signs and neurologic exam. LABS: TSH from 6 mo