Using the coding techniques you have learned, carefully read through the case study…

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. FAMILY DOCTORS ASSOCIATES 123 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234 PATIENT: LAFONE, MICHELLE ACCOUNT/EHR #: LAFOMI001 This patient is a 56-year-old African-American female who is well known to me. Eight years ago, I diagnosed her with type 2 diabetes mellitus, and she is here today for a regular check-up (including her feet) and to go over her most recent lab results. PAST MEDICAL HISTORY: She is currently taking medications to control her blood sugars. She checks herself about once a day, sometimes forgetting, and usually runs around 130s to 160s. She is postmenopausal, overweight, and her blood pressure has been around 142/90 the past several visits. She has no other significant past medical history. She last visited her ophthalmologist 6 months ago and has not had any retinopathic changes yet. SOCIAL HISTORY: She does not smoke or drink alcohol. FAMILY HISTORY: Her father died at age 70 from renal failure from diabetes, but her mother is alive and well, having just had triple heart bypass surgery last year. MEDICATIONS: Metformin, Rosiglitazone LAB RESULTS: Her HbA1c is 8.1%, and she has some microalbuminuria (60mg/L). A BUN and Cr are 35 and 1.3, respectively. A fasting lipid profile revealed total cholesterol 262, LDL 174, HDL 50, triglycerides 162. A: Diabetes mellitus, type 2, essential hypertension Rx: Captopril, 25 mg, tid. I explained to the patient the benefits this medication will have for her, emphasizing its importance in decreasing the progression of renal impairment. I also reiterated to her the importance of controlling her blood glucose levels. She seems to comprehend my advice and agrees to begin taking the Captopril as well as to pay closer attention to her glucose checks.