Determine the Category and Level of the

Determine the Category and Level of the case using MDM. Code this case for accuracy and explain your process using ICD-10-CM and CPT E/M code(s), adding a Level I modifier for the E/M service provided during the encounter. Outpatient Office Visit Patient Case Number: OPOV62-Capelton, Estel Patient Name: Estel Capleton DOB: 06-07-52 Sex: F Date of Service: 10-22-XX Physician: Pedro Hernandez, MD Chief Complaint: New patient is here for hospital follow up for large ovarian mass that looks malignant History of Present Illness: The patient states that she noticed moderate to severe pain left lower abdomen for about 1 week. This got worse and went to ER and was noted to have very large ovarian cyst, suspicious for cancer. Today she says she has pain of about 8/10 particularly when she moves and lays on her left side. She feels that her pain is less when she lays on her right side. She has nausea, no vomiting and has no appetite. She had a little constipation, but now more like diarrhea. Review of Systems Constitutional: anorexia, but negative. Cardiovascular: negative. Respiratory: negative. Gastrointestinal: abdominal pain and vomiting. Genitourinary: negative. Medications: Folic acid, Omeprazole, Salsalate Past Medical History: Noncontributory Surgical History: Tubal ligation Allergy: NKDA Vitals Temperature 98.5 Heart Rate 80 Respiration 16 BP 120/80 Height 5’2 Weight 195 BMI 35.7 LMP Age 55 6/7/2021 OPOV62CapeltonEstel https://myahima.brightspace.com/content/enforced/6681-VLAB_STUDENTPROTO/PatientCaseScenarios/Outpatient_Office_Visit/OPOV62CapeltonE… 2/2 Physical Examination Constitutional General appearance: Normal. Abdomen Abnormal. obese. A cystic mass noted in the mid abdomen and appears mildly tender. Psychiatric Orientation to person, place, and time: Normal. Mood and affect: Normal. Results/Data: Reviewed from ER- has huge complex ovarian cyst, suspicious for cancer. Assessment: 1. Ovarian cyst- patient was given a rx for Norco for chronic pain. Plan for laparotomy and possible staging discussed based on frozen section. Electronically Signed By: Pedro Hernandez, MD

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