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Only assign E/M codes - do not code any other CPT or ICD-10-CM codes. 10. A new patient saw the physician in his office with complaints of diarrhea and watery stools the previous night, as well as, nausea, vomiting, and crampy, lower abdominal pain. The physician performs a medically appropriate history and physical examination. History: The patient has not eaten anything unusual the previous evening - baked tofu and potato, salad, and soft drink. She states that her husband has been sick with the flu for the past 3 days. Mucous membranes are dry. Abdomen is soft, nontender to palpitation with active bowel sounds noted. No guarding, no masses, no CVA tenderness. Patient was given Lomotil to control diarrhea and told to force fluids. Impression: viral gastroenteritis. Time spent was 40 minutes.
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