If you are a frequent reader of “Coding Corner,” you might feel as though you have seen certain scenarios before. However, “Coding Corner”—much like real-life coding situations—may feel familiar, but there are subtle changes to many of the scenarios that will require different coding. Now is the time to sharpen your skills and look for those subtle nuances that could mean the difference between getting paid and being left holding the bill.
A 32-year-old female comes in for an initial office visit. Her primary care doctor is asking for the rheumatologist’s medical opinion. The patient has complained of pain, numbness, and color changes in her fingers when she is exposed to cold. Her right distal index and fourth right finger and left distal index finger will turn white, then blue, when exposed to cold temperatures. She also has pain and numbness in the digits.
These symptoms have been occurring for the past year, but have increased in frequency the past two months. The patient reports that her fingers return to normal color and the pain and numbness resolve after warming of the hands. She has also developed a “sore” on her distal left index finger, and her fingers sometimes feel stiff when she is exposed to the cold.
The patient denies any other musculoskeletal pain or stiffness, and any joint swelling. She also denies fatigue, weight loss, recurrent fevers, rashes, chest pain, dyspnea, cough, palpitations, hypertension, unusual bruising, menorrhagia, dysuria or frequency, abdominal pain, vomiting, diarrhea, constipation, dysphagia, hematochezia, headaches, memory difficulties, insomnia, depression, or weakness. She has no known allergies.
Past medical history: The patient has a history of type II diabetes mellitus. It is controlled with diet and oral hypoglycemic agents. There are no other comorbidities, and there have been no surgeries or hospitalizations.
Family medical history: There is significance for rheumatoid arthritis in her maternal grandmother and type II diabetes mellitus in her paternal grandfather and brother. There is no family history of Raynaud’s phenomenon, lupus, cancer, inflammatory bowel disease, psoriasis, renal disease, or blood disorders.
Social history: The patient is single and lives alone. She has a pet cat and works full-time as a marketing director. She denies smoking and drinks alcohol only on social occasions (two to three times per year). She is sexually active with one male partner and uses oral contraceptives and condoms.
On examination, the patient is alert and oriented with normal vital signs. Her height is 5’7”, weight 140 pounds, and body mass index is 21.9. Her head, eye, ear, nose, and throat exam is normal. There is no lymphadenopathy, and her lungs are clear. Her heart has a regular rate and rhythm with no murmurs or friction rubs, and she has good peripheral pulses. Her abdomen is soft, nontender, with no mass or hepatosplenomegaly. There is no costovertebral angle tenderness on percussion, and the patient’s skin has no rashes. She demonstrates mild cyanosis in distal digits of the right index and fourth fingers and the left index finger. There is a shallow ulcer on distal fingertip of her left index finger.
Musculoskeletal exam: The patient’s gait is normal, and she exhibits good muscle strength in upper and lower extremities, both proximally and distally. All joints are unremarkable with full range of motion and no evidence of synovitis.
Diagnoses:
- Raynaud’s phenomenon
- Rule out other autoimmune connective tissue disease
Plan: The patient is counseled regarding etiology, pathophysiology, symptoms, and prognosis for Raynaud’s phenomenon. Review measures to minimize Raynaud’s phenomenon are discussed, and the patient is provided with written information on Raynaud’s phenomenon. Laboratory studies are ordered to evaluate her for lupus or other autoimmune connective tissue disease, and the patient is started on nifedipine extended release.
The physician reviews actions and side effects of nifedipine with the patient, documents her findings in a written report, and sends it over to the primary care doctor.
How should this be coded?
