Module 6 Teena Kissee Case Study I What are the potential ICD-10 codes in this case? 1. a. 2. How can the NP determine if the patient v/s an established patient at the clinic?

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Module 6 Teena Kissee Case Study I What are the potential ICD-10 codes in this case? 1. a. 2. How can the NP determine if the patient v/s an established patient at the clinic? 3. What components of care will be used for reimbursement decisions for Ms. Ward? 4. What type of physical examination level best fits what was performed on Ms. Ward? 5. If you were coding the list for Ms. Ward, how would you determine what decision-making level you would choose? Provide rationale and be specific Seminar Discussion Questions 3 ρ(4SESTUDY ONE Jenna Ward is a 19-year-old female who presents to the clinic with a chief complai smelling. She has tried OTC vaginal treatment without improvement She has been of 2-day history of burning with urination and vaginal discharge The discharge is fou sexually active with several partners. She is G1, PO, A1.She takes oral contraceptives and menses are regular. She denies any cramping, abdominal pain, or unusual vaginal bleeding. No fever or chills. No routine medications. NKDA Past Medical History: Appendectomy age 16 Family History: M 32 A&W F 33 IDDM, B 22 asthma Smokes /½ PPD, denies alcohol or drug use She is 5’4″ in height and weighs 137 lbs. Her blood pressure is 120/62, P 76. NAD afebrile, abdomen soft, +BS, tender in suprapubic area. GU: external genitalia WNL with thick white vaginal discharge noted. No bleeding noted, Cervix pink, no CMT, GC&Chlamydia cultures taken, wet mount obtained, PAP smear performed bimanual examination WNL no adnexal masses or tenderness abs:UA 20-30 WBCS per HPF/C&S sent, wet mount + whiff test,+clue cells 2 How can the NP determine if this patient is a new patient versus an established patient at the clinic? 1. What are the potential ICD-10 codes in this case? 3. What components of care will be used for reimbursement decisions for Ms Ward? 4. What type of physical examination level best fits what was performed on Ms Ward? 5. If you were coding the visit for Ms. Ward, how would you determine what decision-making level you would choose? Provide your rationale, and be specific

 
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