1. You have completed the below documentation on a patient r

1. You have completed the below documentation on a patient residing… 1. You have completed the below documentation on a patient residing in an Assisted Living Facility (ALF)? Current Medications: ASA 81mg, Losartan 50mgdaily; metoprolol tartrate 12.5mg bid; nifedipine 30mg BID; rosuvastatin 20mg at bedtime. Nitroglycerin 0.4 PRN Tamsulosin 0.4mg daily; MAPAP 1000mg TID daily, Tramadol 50mg BID, Brimonidine Tartrate 0.2% TID; Cetirizine 10mg daily, Clonidine 0.1mg q8hr PRN for SBP > 160 Chief c/o: SHORTNESS OF BREATH  History of present illness: 78-year-old Asian American male.  Discharged from acute care approximately one month ago, due to catheter related UTI 2ND ary to urinary polyps. Pt underwent a bladder polyps removal surgery, D/Ced w/ urology, cardiology & ID F/U. Pt transferred from rehab to ALF yesterday. Pt. c/o SOB and weakness. “I am getting out of breath whenever getting up and moving around” Pt. asked about CHF, “do you know how I recognize that I am having trouble in my heart?” Pt was not able to explain much about what happened during the hospital stay. HH service is set up. PT will be started this Friday.  ROS: : denies fever, chills; admit weakness, fatigue, weight loss, and decreased appetite; denies chest pain, palpitation, but admits SOB in exertion; denies coughing, sputum, or sore throat; denied heartburn, indigestion, dehydration, N/V, constipation, abdominal pain, or diarrhea; denies dysuria or spasm; admit urinary retention; denies depression or insomnia and anxiety.  Assessment: VS 97.6, 80, 18 108/60, o2sat 98 in RA, FBS 125, alert oriented to person, place & time, fatigued, cooperative, casual appearance, spontaneous breathing, free from other s/s of acute distress; S1 S2 regular, S3 heart sounds Present, +2/+4 on bilateral UEs & +1/ +4 on bilateral LEs, no peripheral edema; lungs with clear lung sounds to all lobes. Foley Urine bag w/ clean yellow urine below his leg. Pt’s exercise oxygen test done, O2 sat remaining > 96% while walking around the apartment. After ambulation pt c/o SOB and dizziness. Hospital clinical summary not available at the time.  Medication reconciliation post hospital discharge.  Plan: 1) N390: Urinary Tract Infection: Obtain hospital record. Follow up with urology scheduled2) I50.9: Heart failure, unspecified: Continue HH to assist with HF management and including daily weight and low salt diet.  Follow up with cardiology scheduled3) M62.81: Generalized weakness: PT, Instruct fall prevention.4) I10: HTN: Losartan 50mgdaily; metoprolol tartrate 25mg bid; nifedipine 30mg BID. Clonidine 0.1mg q8hr PRN for SBP > 160. 5) I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris: Nitroglycerin 0.4 PRN.6) HLD: E78.5: rosuvastatin 20mg at bedtime. Plan discussed w/ patients & care-coordination of facility nurse.    2.  The following is documentation you completed on a patient seen in Skilled Nursing Facility (SNF).  Current Medications:  Acetaminophen 325mg 2 tab PO q6h PRN > Acidophilus 1 cap PO QD > Allopurinol 100mg 1 tab PO q12h > Ascorbic Acid 500mg 1 tab PO BID > Aspirin 81mg 1 tab PO QD > Atorvastatin 10mg 1 tab PO qHS > Carvedilol 25mg 1 tab PO q12h > Cholecalciferol 1000 IU 2 tab PO QD > Ciprofloxacin 500mg 1 tab PO QD > Diazepam 2mg 1 tab PO QD > Docusate Sodium 100mg 1 tab PO BID > Doxycycline 100mg 1 cap PO BID > Lutein 20mg 1 cap PO QD > Metolazone 5mg ½ tab PO qMWF > Miralax 3350 17g PO QD PRN > Multivitamin 1 tab PO QD > Nystatin Powder 100000 unit/gm apply to candidiasis of groin BID > Omega 3 1000mg 1 cap PO QD > Pantoprazole 40mg 1 tab PO QD > Papaverine 150mg 1 tab PO BID > Tamsulosin 0.4mg 1 cap PO QD > Torsemide 20mg 2 tabs PO QD > Zinc Sulfate 220mg 1 cap PO QD > Less Follow-up visit 82 y/o M with PMH of HTN, HLD, Chronic diastolic CHF, CKD4, Meniere’s disease, BPH, degenerative arthritis, and BLE lymphedema has chronic LLE cellulitis with wound. VS: 122/62, 72, 16, 98.1, 95%. Wt. 211.6lbs. A/P: Open wound of left lower leg, LLE cellulitis: completed antibiotics today, monitor for s/sx of infection and tx as needed, wound care treating. Acute on chronic renal failure: avoid nephrotoxins, dehydration. Lower extremity lymphedema/Chronic diastolic CHF: weight up 3.2lbs since admission, start Torsemide 20mg 2 tabs daily for edema, monitor renal function and volume status. HTN: cont. present care. Gait instability: cont. PT, OT, mainly in bed exercises for now, still very weak. Meniere’s disease of both ears: cont. present care, sx stable. BPH with urinary retention: cont. present care. Anxiety/depression: cont. present care, consider SSRI/psych referral if needed. Constipation: cont. present care. LABS: WBC 10.0, H/H 10.0/29.6, PLT 181, NA 142, K 3.5, CL 104, CO2 27, CA 8.4, GLU 94, BUN 55, CR 1.58, EGFR 40, Vit D 46, HA1C 5.9. Alert and oriented x3, no acute distress noted, PERRLA, EOMI, MMM, lungs CTA bilaterally, heart RRR, S1, S2, BS present x4, BLE lymphedema, LLE wound to shin, extremities without cyanosis, +2 pedal pulses bilateral. Continue current regimen, PT/OT, f/u in 2 days I50.32: Chronic Diastolic heart failureN18.4: Chronic kidney disease, stage 4 (severe)L03.90: CellulitisZ79.82: long term use of ASAB37.9: candidiasisI10: HTNBPHGait instabilityAnxiety Depression    3. The following is documentation you completed for an Initial Medicare Wellness visit.  67 year old male; last seen 12/20/2020New to your practicePMH: HTN, HLD Medications: HCTZ 25 mg qd; atorvastatin 20 mg q hs.  Social: 34 pack year history of cigarettes (one pack daily for 34 years)Rare beer with friends and familyMarried for 40 years; 2 adult children live in the areaSexually active with wife, prefers womenEducation: Bachelors degree in BusinessBanker: still works full-timeExercise: Walks 2 miles daily Family Hx: Unknown adoptedSurgical History: Tonsillectomy as a child, vasectomy age 40 Allergies: NKDA Other health care providers: Optometrist: Dr. I. Can See (123)-456-7890 Advance care planning: none MMSE: 30/30: Well dressed, well nourished, NAD.  Pleasant, cooperative.Depression Screening: PHQ-depression: 1; Denies sadness or bluesFunctional ability: Katz (IADL): 6/6Barthel (ADL): 100/100Tinneti: 16/16; 12/12; 28/28 No falls.  Normal gait and balance without device.  Reports has grab bars in shower. Maintains all household chores by himself.  Reports good lighting in home.Wears glasses only for reading.  Snellen 20/20Normal whisper test in office: does not wear hearing aides.  98.6 oral; 76; 128/78 L sitting; BMI 25 DRE: approxiately 30 g prostate, no masses, lesions palpable.    Prevention:Lipid panelHgba1cHep CLow dose CT without contrastPneumococcal vaccine todayUS abdomen: AAA screening Education: Counselled to stop smoking.  Offered CBT discussed patches, bupropion declines at this time but will think about it. Dietary consult for heart healthy diet-agreesContinue with daily exerciseDiscussed ACP, provided with Directive to physician and MPOA documents.  He will discuss with wife and bring to next visit. Return to clinic in 6 months sooner if needed.     4.  The following is documentation done on a patient seen in your office within 7 days of hospital discharge. 78 year old female seen in her office after hospital discharge 7 days ago for HFrEF.  MSW called pt on day 2 post dc to check on status, ensure she understood dc instructions and had meds. Discharge summary received from inpatientt team and reviewed prior to visit.Medication reconciliation completed. Hypokalemia while inpatient no labs ordered post dc: will order for follow  up . Has appointt scheduled with cardiologist next week, daughter will take her to this visit.  Meds: Furosemide 40 mg qamPotassium chloride 20 meq qdLisinopril 20 mg qdTylenol 500 mg (2) bidFosamax 70 mg one time weekly, take with full glass of water, sit upright for 30-60 minutes after taking medicationCarvedilol 12.5 mg bidMetoprolol 25 mg bidSertraline 100 mg qd PMH: MI s/p PCI-RCA, HTN, R hip fracture, osteoporosis, MCI, depressionSH: R hip replacement, TAHWidowed-3 children, one lives in area others out of stateRetired RNRare alcohol-wine on holidaysNot sexually active-prefers menLives in retirement community, has a cat named Muffin Pt well known to practice. States was doing well until about 3 weeks ago when she noted increased fatigue and LE edema.  Thinks she had been eating more sodium in her diet, her scale broke and she did not want to buy a new one, did not know if she was gaining weight.  Woke in middle of night with significant SOB, pushed the emergency button in her retirement community and the staff called 911.  Was diuresed in the acute care setting weight is now down 12 lbs.  Echo with EF at 35-40%, mild mitral regurg otherwise no abnormalities. States she feels much better, denies cough, wheeze, SOB, only small amount of LE edema at ankles. Agrees to persistent fatigue but thinks this too is better.  Sleeping well, denies PND. Dtr bought her a scale and she is recording daily dry weight, has changed diet and eliminated extra salt.  Feels that her mood is better denies SI or HI, missed Muffin and is glad to be home.  ROS: General: see HPI, sleeping wellDerm: denies wounds, rashesHEENT: denies vision or hearing problem, denies dysphagia, sore throat, runny/stuffy nose, no oral or dental painLymph: denies masses or lesionsEndo: denies polys, no dry skin, constipation Cardio: denies chest pain, palpitations, see HPIPulm: denies cough, wheeze, see HPIGI: denies N, V, D, C, change in BMsGU: denies pain, burning with urination, incontinence, leaking urineMSK: denies pain, discomfort, has cane but rarely uses itNeuro: denies HA, dizziness, numbness, tingling, problems with coordinationPsych: see HPI VS: T: 97.9 po HR: 60 RR: 17  BP 130/80 L sitting  BMI 24.76 O2 sat 96% RA PE: General: Well dressed, well groomed NADDerm: no wounds, rashes on exposed areasHEENT: PERRLA, oral mucosa pink, moist, good dentation, TMs with landmarks visible bilaterally, nares patent bilaterally with clear scant drainage notedLymph: no masses, lesions palpableNeck : thyroid without lesions/massesCardio: no r, g, III/VI early systolic murmur 2nd LICS radiates throughout precordium, trace bilateral ankle edemaPulm: BBS clear throughout diminished to bases but open with cough and deep breathingGI: soft, nontender, BS + 4 quadsGU: deferredMSK: MAE, gait stable without device, able to rise from chair while holding on to tableNeuro: A, A, O x 3  MMSE: done by MA 28/30Psych: pleasant cooperative Medication reconciliation: pt was not aware she was taking 2 beta blockers—dc metoprolol. Assessment and plan: HFrEF: continue carvedilol, lisinopril, furosemide, potassium.  HHC to help with medications and teaching, reinforce heart failure education (all aspects). Daily wt and record, educate regarding dry wt and to call if she gains 3 lbs overnight or 5 lbs in 3 days.   See above re: beta-blockers (med reconciliation)HTN: see above, has home cuff.  QD BP and record. Depression: continue sertraline and monitorOsteoporosis: continue weekly Fosamax.  Wt bearing exercises as she tolerates. MCI: stable, monitor and supportReturn to clinic in one month and prn.  Bring in wt log, BPs, and all meds.  s 1) For the first patient seen in ALF, what is the appropriate CPT code for this visit?  2) List one other setting of care that is billed like assisted living (hint there is another term for the coding used).   3) For the patient seen in the SNF, what is the appropriate CPT code for this visit? 4) For the patient seen in your office for the Initial Medicare Wellness visit, what is the appropriate CPT code for this visit? 5) For the patient seen in your office within 7 days of hospital discharge. a. What is this visit type called?b. What is the appropriate CPT code for the visit? 6) You have just documented a 10 min session counseling a patient to stop smoking.   Which billing code will you use? 7) You have removed cerumen from a patients ears what CPT code will you use? 8) Medicare denies the above cerumen removal-what is the most likely reason this was denied? 9) A long-time patient in your practice has recently transitioned to hospice.  During the visit which concluded with the hospice referral you explained to the patient and family that you would no longer follow the patient and would discharge from the practice to the hospice provider. The family has now called to make an appoint to discuss hospice recommendations.  Your staff has asked you if you will see the patient and you have agreed.  You have known this patient for years and the patient and family trust you.  Which code will you most likely use to bill for this visit? 10)  Is there a method to bill for a Medicare-Annual Wellness Visit and a continued chronic disease management visit simultaneously?  If so, how do you bill for both of these visits simultaneously?    Health Science Science Nursing NURS 5352

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