Laboratory studies are ordered for lupus evaluation. An MRI/MRA of the brain is ordered to evaluate for central nervous system vasculitis. A nephrology consult is requested and a nephrologist is contacted and arrangements made for the patient to be evaluated later the same day.
The rheumatologist advises the mother that a renal biopsy will probably be needed. She also advises the patient to adhere to a low-sodium diet and provides a diet plan, which is reviewed with both the patient and mother. The patient is also advised to limit sun exposure to the extent that is possible and to use sunscreen with an SPF of 45 or greater when she must be outdoors in sunlight. The mother is advised to call the rheumatologist’s office after the patient sees the nephrologist to review the initial lab results, determine medication therapy, and schedule a followup appointment.
Finally, a report on the clinical findings, impression, and plan is dictated to patient’s primary care provider
How should this encounter be coded?
