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Dr. Carter sees Mrs. White at the Spring Valley Nursing Facility. He saw her last month after she was admitted to the facility. Today is a follow up visit. She is doing well. He documented a medically appropriate history and exam. The patient has osteoporosis, hypertension, dementia. CAD, CHF, and type 2 diabetes (moderate number and complexity of problems). He reviews 4 labs and a telemetry (Moderate data). He adds a Cardizem prescription for better control of her blood pressure which is a moderate risk. What CPT® code does Dr. Carter report for the visit?
(ESTABLISHED PATIENT VISIT: A 37-year-old woman presents with coughing, congestion, upper respiratory symptoms, and headache for two days. Complete ROS negative except as noted. No significant past/family history. Exam: stable vitals, nasal congestion, normal TMs, occasional rhonchi, no wheezing, normal heart, soft abdomen. Assessment/Plan:Acute upper respiratory infection, fluids,amoxicillinfor 5–7 days, return precautions. What CPT® code is reported?)
According to the ICD-10-CM Guidelines, what code is reported as an additional code when the blood pressure of a patient with hypertension remains above goal in spite of the use of antihypertensive medications?