Read the SOAP chart for each scenario. Based on your evaluation of the information in each SOAP chart, complete the ‘Assessment’ for each by…

Question I have an assignment I do not understand FNP-630 Billing and Coding AssignmentPatient Scenario 1SChief Complaints:This assignment has two Patient Scenarios. Read the SOAP chart for each scenario. Based on your evaluation of the information in each SOAP chart, complete the “Assessment” for each by identifying the ICD-10 Diagnostic Code and the Evaluation and Management (E/M) Billing Code for each visit. Provide supporting rationale for why you selected each of the IDC-10 Diagnostic Codes.ubjective1. 7yr female WCC, established patient.HPI:    Well Child Check:        Here with dad for 7yr WCC, doing well. No concerns since last well exam.Nutrition: eating fruits, vegetables, and meats; usually well-balanced diet. Output: stooling and voiding normally. Sleep: all night, normal for age. Gross Motor Development: Likes to play team sports. Fine Motor: handwriting is uniform, draws detailed pictures. Language: defines words, legible printing, reads two-syllable words, counts to 100, adds and subtracts double digits, correctly spells words at grade level. School doing well in school, no concerns per teacher or family, attending 2nd grade. Social Development: follows rules, helps in chores, plays cooperatively, becoming more aware of other people and their relationship to others, increased sense of empathy, concerned with fairness, has friends. Development: discussed body changes. Oral Health brushing teeth 2x/day, next dental visit discussed and recommended for every 6months.Medical History: Pregnancy without complications, Normal Spontaneous Vaginal Delivery at 39 weeks gestation; born in Colorado; home birth without complications, Birth Weight 7lbs, Jaundice at 4 days-needed bili-blanket at home, Breast-fed for 12 months.Surgical History: Denies Past Surgical History.Hospitalization/Major Diagnostic Procedure: Denies Past Hospitalization.Family History: Father: alive 48 yrs, Healthy. Mother: alive 42 yrs, Healthy. Paternal side: Addiction, Cardiac. Maternal side: Addiction, HTN, High Cholesterol, Cardiac, Lung cancer.  1 sister(s) – alive, age 3, healthy.Social History: Parental marital status: married. Parent employment: Dad-Art Gallery and yoga teacher Mom-yoga teacher. No Daycare. School: Pueblo Elementary. No Family smoking. Pets: Yes, 2 dogs. No Guns in the home.Medications: NoneAllergies: N.K.D.AROS:  Constitutional:        No fever. energy level normal. weight change yes, adequate weight gain. No Pain. sleep normal. appetite normal.  HEENT:        No hearing concerns or vision changes. No ear pain or drainage No nasal discharge or cough.    Cardiac:        No chest pain. No palpitations or edema.Respiratory:        No shortness of breath. No asthma history. No wheezing. No chest congestion.Integumentary:       No rashes. No moles or wartsMSK:       No joint pain. GI:      No gas concerns. No diarrhea or vomiting or nauseas. No constipation or blood in the stool.GU:      No pain with urination. No bed wetting/accidents.Neuro:      No headaches. No history of convulsions or seizures.Psych:       No anxiety, depression, or suicidal ideation  ObjectiveVitals: Weight 23.0 kg (50.6 lbs), Weight percentile 42.92 %, Height 121.25 cm, Height percentile 33.58 %, BMI 15.64 index, BMI percentile 52.1Temperature 98.0 F oral, BP 98/55 mm Hg, RR 24 /min, HR 112 /min, O2 sats 99,Vision Screen: OU/OD/OS spot vision (ocular photo-screening) see belowHearing Screen: (L) pass, (R) passExamination:General appearance: NAD, well-developed, well-nourished.       HEENT: conjunctiva normal, TMs pearly bilaterally, pharynx and tonsils non-erythemic without exudate, PERRLA, EOM’s Intact, positive red reflex.       Oral cavity: moist mucous membranes, no lesions.       Neck: supple, no lymphadenopathy.       Heart: Regular rate and rhythm, normal S1 S2, no murmur.       Lungs: good air exchange, no distress, no wheezes or crackles, clear to auscultation bilaterally.       Abdomen: soft, non-tender/non-distended, bowel sounds present and active in all quadrants, no masses, no hepatosplenomegaly.       Extremities: normal ROM, normal gait.       Skin: moist, warm, no rashes      Back: no evidence of scoliosis.       Neuro: Normal gait, tone, and posture.       GU/Genitals: Normal external genitals, tanner stage IAssessmentComplete the following:ICD-10- Diagnostic Code(s) (no need for procedural CPT codes). Provide supporting rationale for your selection: (5 points)Evaluation and Management (E/M) Billing Code for visit (5 points):Plan1. Encounter for routine child health examination without abnormal findings Notes: Reviewed development, activity, nutrition, safety, and hygiene for this age. Anticipatory guidance given regarding safety as well as nutrition. Reviewed growth percentiles. Age appropriate advice given. Answered parental questions and concerns. Bright Futures age appropriate handout given. If referral is placed for specialist visit, parent will be contacted with information. Arizona State Immunization Information System (ASIIS) records checked and immunization record in chart updated accordingly. Procedures:     Vision screen:        Spot Vision (Ocular photo-screening) Done, Passed, OD -0.75 OS 0.00.Immunizations:    No vaccines due todayPreventive Medicine:      Child:   Dental/tooth brushing. Daily brushing & flossing 2x daily. Remember to schedule dental appointments every 6 months.  Growth discussed. Development discussed. Nutrition/Vitamins. Dental care. Reading. Exercise recommended daily for 30 minutes. Chores/rules discussed. Limit television/internet/screen time to 1-2hrs/day. Follow Up: well child in 1 year, prn concerns.     Patient Scenario 2SubjectivePatient name: M.G. 40 years oldVisit Type: New patient. Woman well-check examinationLocation: Family Health ClinicDate of Visit: 2/2/2021Chief Complaint: “I came today for my annual well-woman examination”History of Present Illness: M.G. is a 40-year-old Caucasian woman with no significant past medical history. She denies any complaints and she feels she is in a good state of health. She explains it has been over 2 years since a doctor last saw her, and she is overdue for an annual physical examination.Past Medical History:  Mrs. M.G. states the onset of puberty began around age 12 years old, which initially was marked by breast development and menarche at 12 ½. She says her periods were regular up until she was about 22 years old. The irregularities in her menstrual cycle was marked by some skipped months, heavy menstrual bleeding and dysmenorrhea. She was prescribed birth control pills to help with her symptoms. She explains she was 22 years old when she had an abnormal pap smear. She followed through with a tissue biopsy that showed endocervical cell changes. After, she decided to have a colposcopy with the removal of the abnormal cells. She states her doctors recommended annual pap smear screening, which she has had for the last years and all of them have been normal. Her past medical history is significant for gestational diabetes in 2019. She explains her gynecologist referred her to a perinatal specialist who put her on glyburide 5 mg daily in her third trimester. She has been married for 6 years and she is sexually active with her husband. She has 2 children, and both were vaginal birth delivered with no complications. She says she has an IUD (Mirena) placed in 2020 after her son’s birth, and her periods has stopped ever since. Surgical History:·       Colposcopy in 2003Allergies: ·       Sulfa (hives and itchy throat)Medications:1)     Multivitamin 1 tab daily 2)     Herbal tea at nighttime to help with sleepImmunizations: Influenza: 11/23/2020Tdap: 8/12/2010 Td booster: 10/3/2020Family History:Maternal Grandmother: age 79 y/,. Hx of HTN, DM, hyperlipidemia, osteoporosis Maternal Grandfather: deceased age 75 y/o from PE. Hx of dementia, alcohol abuse, Paternal Grandmother: deceased age 82 from unknown cause.Paternal Grandfather: deceased age 60 from unknown cause.  Mother: age 60 y/o. DMFather: age 60 y/o. DM, HTN, MI with CABG, hyperlipidemia, Brother: age 42 y/o. Obesity, hyperlipidemia Sister: age 25 y/o. Healthy Daughter: 4 y/o. HealthySon: 6 months old. Healthy Social History: Mrs. M.G. is a pleasant 40-year-old woman born and raised in Phoenix, Arizona. She lives a one-story family house with her husband and her two children. She states her economic status is middle class and she has access to healthcare through privately owned insurance. M.G. works as a nurse at a local hospital during grave hours. She says she tries to balance her diet by eating a variety of healthy food; however, she says she never has time to cook a healthy meal. M.G.’s dietary habits consist of skipping breakfast in the morning, having pizza or a cheeseburger for lunch, and fast food for dinner right before work. She explains she drinks 5 cans of diet coke while working, which seems to help by keeping her awake. She says she maybe has a glass or two of water in a day. She denies smoking or the use of illicit drugs. She occasionally has a drink containing alcohol once a week on her days off.  She explains,  she doesn’t have any time for physical activity because she is always busy with the kids. She is Christian, and she enjoys going to church on Sundays with her family. Risk Factors: family history of DM, poor diet intake, physical inactivity, overweight/obesity, diabetes, hyperlipidemia, heart disease, and metabolic syndrome.Review of System: General: (-) fevers, (-) chills, (-) recent illness, (-) loss of appetiteNeurologic: (-) seizures, (-) tremors, (-) memory loss (-) gait problemsHEENT: (-) head pain, (-) headachesEyes: (-) blurry vision, (-) double vision, (-) itching eyes, (-) watering eyes, (-) eye pain, last eye exam: 2/27/2020Ears: (-) problems with hearing, (-) ear pain, (-) ringing in the ears (-) drainage from earsNose: (-) runny nose, (-) problems with sense of smell, (-) problems with airflow through nares (-) bloody nose, (-) sores in the nose, (-) snoring Mouth/Throat: (-) sore throat, (-) problems with swallowing, (-) oral lesions, (-) tooth pain, (-) problems with chewing or swallowing, (-) loose teeth, last dental exam: 3/26/2019Cardiovascular: (-) chest pain, (-) SOB with or without exertion, (-) racing heart, (-) irregular heartbeat, (-) swelling of feet or legs, (-) pain in legs when walkingPulmonary: (-) cough, (-) wheezing, (-) sputum productionGI: (-) blood in stool, (-) constipation, (-) diarrhea, (-) abdominal pain (-) nausea or vomiting (-) heartburn, (-) change in bowel habitsGU: (-) pain with urination, (-) frequent urination, (-) urinary urgency (-) blood in urine, (-) cloudy or foul-smelling urine, GYN: (-) irregular menses, (-) bleeding problems, (-) premenstrual symptoms,M/S: (-) pain or swelling in joints, (-) problems with ROM (-) muscle pain Dermatologic/Breast: (-) rashes, (-) lesions, (-) open wounds/sores, (-) changes to nevi, (-) breast changes Psychiatric: (-) feeling depressed (-) feeling anxious, (-) suicidal thoughts, (+) insomniaHematologic: (-) easy bruising, (-) abnormal bleedingEndocrine: (-) feeling abnormally hot/cold, (-) hair loss, (+) weight loss/ gainAllergic/Immunologic: (-) frequent infections, (-) fevers, (-) hay fever symptoms, itchingObjectiveWeight: 81.8 Kg           Height: 5’5”        BMI: 30 (Obesity) Waist circumference: 36 inchesVital Signs: BP: 130/76P: 72T: 36.9O2: 98 on R/APhysical Examination ·       General: Patient is sitting on the examination table, posture upright, shows no signs of distress, A& O x 3. Hygiene clean, well-groomed, and no malodors. Appears older than stated age, well-nourished and hydrated. She is attentive and her mood and affect is pleasant. ·       Head: Skull is normocephalic, atraumatic to palpation. There is thinning of the hair with some hair loss in in the frontal area. Scalp is free of dandruff or nevi, no lesions noted.·       Eyes: Pupils are 3 mm constriction to 2 mm, PERRLA, EOM intact, no nystagmus noted. Red reflex present. Fundoscopic examination with retina and vessels visible and no abnormalities, optic disc and cup ratio 1/3 ratio, maculae and fovea visible with light reflex. Visual acuity 20/20 with corrective glasses. No eyelids swelling, erythema or discharge. ·       ENT: External ear canal free of obstruction or tenderness to pulling test. TM with gray/pearly color appearance, the inner ear bones: the incus and the malleolus visible, along with the cone of light. Hearing test passed to both ears to whispered test. Nose: Symmetrical, patent, no nasal flaring, discharge or obstruction. Mouth: Wisdom teeth missing; mucous membrane moist; tongue symmetrical and no lesions noted, tonsils grade +1. Neck: Trachea at midline; thyroid gland palpable with no lobes or goiter. No tonsillar, anterior and posterior cervical lymphadenopathy noted to palpation. ·       Neurological: Oriented to time, place and person, follow commands and oriented to surroundings. Romberg test negative and performed heel-to-chin test without any problems·       Cardiovascular: Chest symmetrical, no heaves or lifts noted. Negative JVD; carotid arteries +2 to palpation and without bruit. PMI palpable at the 5th intercostal space. Heart sounds S1and S2 auscultated with normal intensity and rhythm, no murmurs or extra heart sounds. No edema to bilateral lower extremities and warm to touch. ·       Respiratory: Chest symmetrical without any tenderness to palpations. Chest expansion symmetrical with 2/1 AP diameter. Lungs sounds are clear to bilateral upper and lower lobes.·       GI: Abdomen is flabby and soft to palpation without any tenderness. No deformities, scar, masses or pulsations are noted. Spleen and kidneys are non-palpable. Bowel sounds are present to all 4 quadrants and normoactive. ·       Musculoskeletal: Upper and lower extremities equal and symmetrical. No erythema, joint swelling, or deformities noted. Active ROM and muscle strength is 5/5 to bilateral upper and lower extremities. ·       Dermatologic/Breast: Normal for ethnicity, pink and warm to touch. Nails beds are pink and capillary refill less < 3 sec. Breast are symmetrical, soft to palpation without any lesion, nodules, nevi or masses. Pectoral, subscapular, lateral, supraclavicular and infraclavicular lymph nodes palpable and with no enlargement.·       Genital: External genital without lesions, erythema or nodules. Uterus anterior, cervical os at midline with no lesion or discharger. Vaginal wall pink without ulceration, nodules, masses or discharge. Bimanual examination with no cervical motion tenderness, pain or tenderness. ·       Psychiatric: Pleasant, cooperative and attentive. Participates in own care is able to demonstrate appropriate interaction with the provider. Speech is clear and coherent. A&O x 3 and memory is intact.Lab Diagnostic/Test ·       Pap smear with HPV co-testing: 8/20/2017- normal pap smear, no HPV detected AssessmentComplete the following:ICD-10- Diagnostic Code(s) (no need for procedural CPT codes). Provide supporting rationale for your selection: (5 points)Evaluation and Management (E/M) Billing Code for visit (5 points):PlanTreatment Plan:·       Screen patient for risk of cardiovascular disease and metabolic syndrome by BMI and measuring waist circumference. ·       Laboratory blood testing: CBC w/ differential; fasting blood glucose; A1C; lipid panel; thyroid panel; kidney function; liver function test·       Breast cancer screening with a mammogram (GCU, 2020)·       Pap smear with HPV co-testing collected and will be send out ·       Screen for partner violence using the Hurt, Insult, Threaten, Scream (HITS) ·       Screen for depression by using the PHQ-2 screening tool·       Follow up in 2 weeks to discuss laboratory results Anticipatory Guidelines:·       Counsel about healthy eating by limiting the amount of fat and cholesterol in her diet. Health Science Science Nursing FNP 630 Share QuestionEmailCopy link Comments (0)