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: ESTRADA, DAWN ACCOUNT/EHR #: ESTRDA001 S: This new patient is a 35-year-old African-American female complaining of pain when she urinates. She is a divorced mother of three children ages 3, 5, and 9. She states she has multiple sexual partners. She has not used any form of birth control since undergoing tubal ligation after the birth of her last child. She is not sure when her last menstrual period was because her menses have always been irregular. She thinks it was 6 weeks ago. Other than a recent URI, she states that she has been in good health. She has no other complaints. HISTORY OF PRESENT ILLNESS: Upon further questioning I learned that this patient has been experiencing mild pelvic pain. She also says that she feels like she “always has to go.” She has been waking up four or five times at night to urinate for the last two nights. Although she has not taken her temperature, she has felt warm now and then over the past week, but she dismisses this as part of her recent cold symptoms. She denies blood in her urine, chills, or an increased sense of urgency to urinate. She has never had a urinary tract infection. She admits that she has been feeling fatigued and run down lately. Her job is becomingly increasingly stressful as she takes on more responsibility. When asked about her sexual history, she states that since the divorce she has been seeing a few guys she met in local clubs. She refers to this as “sowing her wild oats.” She says she married and had children at such a young age that she missed out on a lot of the experiences other women her age have already enjoyed. She loves her children but finds them overwhelming when they “act like little devils.” PAST MEDICAL HISTORY: Asthma, allergic rhinitis PAST SURGICAL HISTORY: Appendectomy age 13; tubal ligation after the birth of her last child MEDICATIONS: Albuterol inhaler and Claritin, as often as she can get samples from the city clinic SOCIAL HISTORY: Patient works full-time as an assistant manager in a retail store. Only recently has she begun receiving health insurance benefits. She has not had regular annual gynecologic exams or received any consistent health care. She drinks two to three beers per day, usually more on the weekends to help her deal with the stress of her children. She denies tobacco or illicit drug use. FAMILY HISTORY: Mother—diabetes type 2, hypertension. Father died last year of an MI at age 60. O: PHYSICAL EXAMINATION VITA