Case Study One Becky Carr is a 57-year-old African-American female who presents

Question

Case Study One

Becky Carr is a 57-year-old African-American female who presents to the clinic with a chief complaint of bilateral heel and knee pain. It is described as an ache in the morning that gradually eases up during the day. The patient does not engage in a regular exercise program. She has recently started working outside the home stocking shelves in a discount merchandising store, and she notices she gets a little out of breath at work or when climbing the stairs at home. She is G 4, P 4, A0, L4, and postmenopausal for 6 years. She has a 15-year history of hypertension and was told she has “sugar diabetes,” which is currently diet controlled. She is 5’4” in height and weighs 301 lb. She states she needs to lose weight and has tried everything, but no diets work for her. Her blood pressure is 150/90, with her other vital signs being normal. Labs: 2 hour postprandial blood glucose = 230, UA = 1 + protein, 1+ glucose, moderate WBCs.

The general examination is remarkable for obesity and an erythematous rash underneath both breasts and in the groin area. She has bilaterally tender heels at the insertion of the long arch. She has moderate crepitus of the patellar joints R > L.

Past Medical History:

Osteoarthritis

Type 2 diabetes

Hypertension

NKDA

Medications: Naprosyn 550mg PO BID

Norvasc 10mg PO QD

Family History: Mother 75 y.o. with type 2 DM, HTN, CAD

    Father deceased at 62 y.o. CVA

Social History: Married for 30 years to Howard Carr, a postal worker

4 children, 8 grandchildren
Smokes ½ PPD, denies alcohol or drug use

1.  What are the potential ICD-9 codes in this case?

2.  How can the NP determine if Ms. Carr is a new patient vs. an established patient at the clinic?

3.  What components of care will be used for reimbursement decisions for Ms. Carr?

4.  What type of physical examination best fits what was performed on Ms. Carr?

5.  If you were coding the visit for Ms. Carr, how would you determine what decision-making level you would choose? Provide your rationale, and be specific.

Explanation / Answer

1. Potential ICD-9 codes in this case are:

Maintaining her health condition as per standard designed proyocol.

As family history is already known a well design therapy plan can be implementated.

Classification of disease based on her current symptoms can be categorised

2 Identification criteria of Ms. Carr as an establoished patient can be verified by the details of her medical distory and family history available in the database in details This data's helps in follow up treatment and taking further decision with regards with patient

3. Dietary plan according to increase BMI intex ratio can be prepared as she has to lose weight in order to control her health related complication.

A target BMI should be in the range of 25-29 at her height should be achieved.

4. 2 hour postprandial blood glucose = 230, UA = 1 + protein, 1+ glucose, moderate WBCs

The above parameters are best fits examination was performed on her as glucose elevation can be seen in the data.
5. Based on her family history and her current obese and sugar status I would coded for her a strict sugar free diet plan and regular exercise for 30 minutes in her chart in order to control her elevated weight. As these two factor plays a major role in her health condition.

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