Psychiatric: She has a normal mood and affect. Neurological: She is alert and oriented to person, place, and time. Pulmonary/Chest: Effort normal and breath sounds normal.Ībdominal: Soft.
Neck supple.Ĭardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Pupils are equal, round, and reactive to light. Mouth/Throat: Oropharynx is clear and moist.Įyes: Conjunctivae and EOM are normal.She appears well-developed and well-nourished. Respiratory: Positive for shortness of breath.Ĭardiovascular: Positive for palpitations.Īll other systems reviewed and are negative.Ĭonstitutional: She is oriented to person, place, and time. Patient presents with issues with palpitations and "not feeling right" Diabetes mellitus in pregnancy, childbirth, and the puerperium.Drug or chemical induced diabetes mellitus.When documenting diabetes, include the following: This scenario involves a patient presenting with symptoms of type 2 diabetes see if you can choose the correct codes.
In our Coding Case Studies, we will explore the correct coding for a specific condition based on a hypothetical clinical scenario. In the medical billing and coding field, getting paid requires accurate documentation and selecting the correct codes.
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