Reference no: EM133224520

Coding and Billing

PART ONE:

You are a dietitian, working in an outpatient clinic setting. Your facility requires you to fill out basic coding and billing information at the top of every note that you write. Read each of the scenarios below and then fill out the form representing the top of the note.

Use ICD-10-CM codes. Note that in actual practice, you will defer to the system your employer uses and codes may be different.

Scenario #1

You just saw Susan for the first time for a one hour appointment. Her appointment started at 1:10pm (your prior appointment ran over by 7 minutes). She was referred to see you due to a recent diagnosis of Type 2 diabetes. She has never seen a dietitian before, and she has no other complications or concerns at this time. Since this was your first appointment with her, you completed a nutrition assessment and gathered information on her family, work, eating habits and a brief medical history. She is a single mom with two children and works at a bank. She often eats on the run and both her and her kids grab snacks or pick up takeout between work, school, soccer practice and dance lessons. She said they prioritize breakfast as a family and always sit down to eat together in the morning. Her boss is good about making sure everyone takes breaks, so she gets 30 minutes away from her desk for lunch each day, but usually uses the time to run errands and then munches on leftovers, chips or snacks from the vending machine through the afternoon. You provided Susan with some handouts to educate her about diabetes and gave her some basic education about carbohydrates.