Read the physician note and abstract the information that is needed for a correct code assignment. 

Question Answered step-by-step Read the physician note and abstract the information that is needed for a correct code assignment. Assign the correct CPT code ________Chief Complaint: 40-year-old male presents today for his annual check-up. HPI: He has no new complaints. He has no chronic medical conditions, but for reflux that he has previously managed with Tums. He has noticed that it tends to flare up more often and usually when he’s consumed alcohol, raw onions or spicy foods. PFSH: He is a nonsmoker. Family history of breast cancer on maternal side. GENERAL: Well developed, well-nourished, alert and cooperative, and appears to be in no acute distress. HEENT: Normocephalic. PERRL, EOMI. Fundi normal, vision is grossly intact. External auditory canals and tympanic membranes clear, hearing grossly intact. No nasal discharge. Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. RRR. There is no peripheral edema, cyanosis or pallor. No carotid bruits. LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses. MUSCULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait. Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm. EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities. Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation without tenderness, swelling, discoloration, nodules, weakness or deformity; Herzing University Medical Center examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity. NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal. SKIN: Normal color. No lesions or eruptions. PSYCHIATRIC: AOx3. The patient was able to demonstrate good judgment and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. RECTAL: Good sphincter tone with no anal, perineal or rectal lesions. Prostate is not tender, enlarged, boggy, or nodular. GENITALIA: Genital exam revealed normally developed male genitalia. No scrotal mass or tenderness, no hernias or inguinal lymphadenopathy. No perineal or perianal abnormalities are seen. No genital lesions or urethral discharge. ASSESSMENT AND PLAN: 1. Schedule upper GI 2. RTC in one year as needed. Health Science Science Nursing HI MC165 Share QuestionEmailCopy link Comments (0)