Assign the correct codes for the following scenario using ICD-9-CM, ICD-10-CM codes, and CPT procedure codes:
This known patient presented for her annual preventive exam.
The patient had no acute complaints and stated that she was in good health. She had no vaginal bleeding or problems and has a history of hysterectomy. She was sexually active, but with decreasing frequency. Her only physical complaint was occasional catch in her right hip. No associated swelling, inflammation, or pain.
Inderal LA 80 mg every other day
History of rosacea, tremors treated with Inderal, hysterectomy 10 years ago
Married and caretaker of her husband who has difficulty with his nondominant arm and shoulder. She walks nearly every day. Up to four cups of coffee a day, but no soda or chocolate.
Father died of congestive heart failure at age 86. Mother had a stroke at age 92 and is in a nursing facility. One brother with kidney failure; the other brother donated a kidney and is subsequently addicted to alcohol and drugs. She has two daughters and one son in good health.
Review of Systems
She fell and hit her head about six months ago and had intermittent headaches but no cerebral bleeds by history. No blurred or double vision, no tinnitus, infection, or hearing problems. She reported having an occasional sore throat. No shortness of breath, cough, chest pain, palpitations, hypertension, or edema noted. She denied nausea, vomiting, diarrhea, or constipation. No stress incontinence, frequency, or urgency but she reported waking several times in the night to urinate. No muscle or bone pain or weakness other than noted above. No postmenopausal bleeding. Patient denied any breast tenderness, mass, lumps, or discharge. She denied depression or anxiety. All other systems were negative.
5 feet 5 inches tall, 165 pounds. Blood pressure 116/80, pulse 62 and respirations 18. This 61-year-old female was well-nourished and well-developed with good mentation and appropriate answers.
Head was normocephalic.
Extraocular movements intact, pupils equal, round, and reactive to light and accommodation. Patient wears glasses for both near and far vision.
Tympanic membranes were intact.
No oral lesions, mucosa moist, tonsils present, noninflamed.
No thyromegaly or lymphadenopathy.
Lungs were clear to auscultation and percussion.
Heart was regular rate and rhythm without murmur.
Breasts were normal appearing for age, nontender, no masses or lumps, nipple discharge, or retraction.
No axillary nodes detected.
Abdomen was soft, nontender, no masses. Bowel sounds were present.
Pulses present in all four extremities with reflexes intact. No edema detected. Gait was normal.
No spinal tenderness of deformity.
Vaginal mucosa was atrophic, cervix and uterus absent. Pap smear was taken and sent for pathology evaluation. No adnexal masses. Rectal tone good, no masses and stool guaiac negative.
Middle-aged woman in good health, status post hysterectomy not on hormone replacement.
She has not had her routine health screening for at least five years. Screening will be ordered. Encouraged patient to keep yearly evaluation appointments.
Will see her in one year unless she has health issues.
Select the correct CPT, ICD-9-CM, and ICD-10-CM codes for this office visit.