Using the coding techniques you have learned, carefully read through the case study and determine the most accurate diagnosis code(s). Remember, check the chapter-specific, subchapter-specific, and category-specific notations within the Tabular List. Then, determine the most accurate procedure code(s) along with any modifier(s), if appropriate. MORRIS, SHALLERT & ASSOCIATES Allergy & Immunology 975 CENTRAL AVENUE • SOMEWHERE, FL 32811 • 407-555-4321 PATIENT: TRUMAINE, BARRY ACCOUNT/EHR #: TRUMBA001 S: The patient comes in today for follow-up. He has had allergic rhinitis, along with a rash that was difficult to make go away. After doing significant exploration, he finally determined that it was Entex that was causing him to get the rash repeatedly. He apparently has taken Sudafed since then, without substantial rash. He states he still continues to smoke. He needs a refill on his Zyrtec. He would like to, perhaps, try Zyrtec D, if that is not going to cause him a rash. I warned him against using guaifenesin, as that is likely his allergic component. O: Blood pressure 102/70, pulse 86, respirations 18, weight 149 pounds. Tympanic membranes clear bilaterally. Nares congested with clear rhinorrhea. Pharynx clear. Neck supple with full range of motion. No adenopathy. No thyromegaly. Lungs clear to auscultation bilaterally. Heart regular rate and rhythm. A: Allergic rhinitis P: The patient will be given Zyrtec D, 1 tablet twice a day (#10 samples given). The patient will follow up as necessary. Should he develop a rash or reaction to medication, he is to stop immediately and use Benadryl. The patient will otherwise follow up as directed. Should he experience any problems, he will follow up accordingly.
Using the coding techniques you have learned, carefully read through the case study…
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