2017 Physician Coding for CPC Preparation ,2017 Physician Coding for CPC Preparation

2017 Physician Coding for CPC Preparation ,2017 Physician Coding for CPC Preparation , Operative Report PREOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. POSTOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. (Postoperative diagnoses are reported.) OPERATIVE PROCEDURE Dear Dr. Smith, Mr. Martin was seen in the office for continued management of his breast cancer.(This indicates the patient's main reason for the office visit.) He’s having someincreasing pain in his breast which is due to the cancer.(Pain related to the neoplasm.) He is also complaining of neck pain. It does not seem to be worse at night; it seems to be worse with activity. He has no other symptoms. Otherwise his review of systems is unremarkable. He’s had no constitutional symptoms. On physical exam, he is alert and oriented. Eyes: EOMI, PERLA, no icterus. The heart had a regular rate and rhythm; S1, S2 within normal limits. The lungs are clear to auscultation and percussion. The abdomen was soft, without masses or organomegaly. He was tender to palpation over the left anterior iliac crest. Otherwise he had no point tenderness over his musculoskeletal system. Neck: Supple. No tenderness, no enlarged lymph nodes in the neck. ASSESSMENT: Adenocarcinoma of the left breast, stage IV, positive estrogen receptor status. Neck pain. (This is the definitive diagnosis that is reported.) PLAN: The plan is to continue the Tamoxifen at this time. His laboratory studies were reviewed and were essentially unremarkable; however we’ll obtain a bone scan to ascertain the extent of his disease.(This is a male patient.) Sincerely, John Smith, M.D. What diagnosis(es) code(s) are reported? [a] [b] [c] [d] [e]