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

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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: BASCINTRASEN, ERNEST ACCOUNT/EHR #: BASCER001 History: This 47-year-old male has a history of chronic sinusitis with perennial nasal allergy and several attempts at desensitization using allergy injections. He had several sinus surgery procedures for chronic sinusitis and removal of nasal polyps. He is seen today for the first time and volunteered that he has been “sick all his life.” He complained of nasal stuffiness, sinus pressure, ear pressure, and constant postnasal drainage. He had episodes of asthma that were particularly bad in May when boating on a lake. He frequently felt short of breath with wheezing and had sinus headaches through the frontal and maxillary areas. He had the diagnosis of celiac disease made through a blood test and avoids wheat and gluten. He had eczema as a child and still has occasional patches on the elbows. His previous allergy treatment was at a local hospital, where he was treated with antihistamines and topical nasal steroids as well as Atrovent and albuterol lung inhalers. EXAM: He had small nasal polyps bilaterally with much lymphoid hyperplasia in the posterior pharynx and postnasal drainage. The exam was otherwise normal. SKIN TESTING: Performed today in our office, he reacted quite strongly to dust and dust mites and to the molds and formalin but did not react to ragweed mixture, grass mixture, or Midwest tree mixture. PROGRESS NOTE: The patient will be started on treatment 7/24/25 with sublingual antigens appropriate for the testing results for dust, dust mite, Alternaria, Cladosporium, Aspergillus, Penicillium, and four other mold mixtures. (He also reacted to formaldehyde, and this was included in the sublingual antigen.) He was given a prescription for Sporanox capsules to be taken twice weekly for yeast and mold colonization. He should continue the sublingual antigens and will be seen again in 4 to 6 weeks. Suzanne R. Shallert, MD Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2.

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