This article provides a Nursing Discussion Sample.
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Nursing Discussion Sample
Unit 2 Discussion
A review of the SOAP note made me consider assigning the code 99204. Under this code means, the physician sees a new patient presenting for an office visit or other outpatient visit that entails evaluation and management. According to CPT 999304 (2021), the visit comprises a moderate level of medical decision-making where the physician spends between 45 and 59 minutes on a specific encounter within a particular date.
The logic used to select this case code 99204 was premised on medical decision-making where the overall complexity is high as the 75-year-old man has major depression manic that poses a severe threat to his life. With an F32.1 major depressive, single episode, moderate, it means at least one symptom is either a depressed mood or loss of interest for the better of the day nearly every day. The geriatrics-depressed mood involves a markedly diminished interest in pleasure in many of the pleasure activities. Secondly, the R45.81 suicidal ideation is assigned as the principal diagnosis. The provider has confirmed no underlying mental disorder under the WA Coding Rule 0318/69 as modified to correspond with the updated ICD-10-AMA/ACHI/ACS Tenth Edition.
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Most importantly, the amount and complexity of data under review and analysis are low (1 point). On the other hand, the patient has a high (4 points) risk of complications and or morbidity considering the risk of fatality emanating from his suicidal ideation with available weapons and a plan to execute the suicide plan. The presence of these two or more components necessitates that high level (American Medical Association, 2021).
The memory issues he experiences could be attributable to depression and sleeplessness. Bachman (2018) points out that older patients have higher success rates in executing their suicide plans. In general, this patient has several major risk factors and few protective factors for suicide hence the assigned coding.
References
American Foundation for Suicide Prevention. (2021). Suicide statistics. American Foundation for Suicide Prevention. https://afsp.org/suicide-statistics/ (Links to an external site.)
Bachmann, S. (2018). Epidemiology of suicide and the psychiatric perspective. International journal of environmental research and public health, 15(7), 1425.
CPT 99204. (2021, January 1). Codify by AAPC. https://www.aapc.com/codes/cpt-codes/99204#:~:text=The%20Current%20Procedural%20Terminology%20%28CPT%20%C2%AE%29%20code%2099204,and%20get%20the%20code%20details%20in%20a%20flash. (Links to an external site.)https://www.mssny.org/Documents/2016/Practice%20Resources/Coding_Handbook.doc_6-16-09-Revised_8-14-09-add.pdf
