Code the E/M code and any other procedures for the following case from your CPT coding book and add modifier if applicable:PATIENT: KILLBURN, JOHNACCOUNT/EHR #: KILBJO001DATE: 10/11/21Attending Physician: Katie M. Robbs, MDThe patient is a male, gestational age 41 weeks, 5 days, born by Cesarean section in this facility, 10/10/21, 27:37. This is a subsequent hospital visit.IMPRESSION: Neonate was of a single birth, BWT 2,857 grams without significant OR procedures with a normal newborn diagnosis. 21? long. Head circumference: 31 cm. Amniotic fluid: clear. Cord: 3 vessels. Head is acrocephalitic, and there is evidence of premature cranial suture fusion. The fingers of the right hand are syndactylic, as well.APGAR SCORE: 1 min. = 7; 5 min. = 8. Heart rate: 100; respiratory effort: good; muscle tone: active; response to catheter in nostril: cough; color: body pink, extremities blueMATERNAL HISTORY: 40 years old, G2P2, blood type B+ , planned C-section due to previous C-section birth three years ago. General anesthesia. HIV-tested during pregnancy: neg.ADMINISTRATIONS: Hepatitis B, peds, vaccine (recomb) 5 mcg/0.5 mL, given: 10/12/21RECOMMENDATIONS: Newborn has acrocephalosyndactyly. Consultation with neonatologist requested.Katie M. Robbs, MDPHJ/mg?D: 10/11/21 09:50:16?T: 10/13/21 12:55:01
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