The patient is a 38-year-old male who is admitted for repair…

The patient is a 38-year-old male who is admitted for repair of a right hiatal hernia that is causing reflux esophagitis. The patient admits to smoking 1 PPD for the past 15 years. The patient also has HTN that is well-controlled on his current medications, and he has type 2 DM that is well-controlled on injectable insulin.  The patient underwent repair of right esophageal hiatal hernia, open approach. The patient tolerated the procedure well. The patient will be rechecked tomorrow and may be discharged home at that time.  Principal Diagnosis: Diagnosis: Diagnosis: Diagnosis: Diagnosis: Diagnosis: Principal Procedure: Procedure:  

Skilled nursing facility progress note: “This 84-year-old pa…

Skilled nursing facility progress note: “This 84-year-old patient was seen today because the nurse asked me to examine the patient’s back. Exam: HEENT: no findings. Abdomen: bowel sounds are normal. Lungs: clear. Skin: on the left buttock there is an area of cellulitis, and on the right side of the chest wall there is also an area of cellulitis. I informed the nurse that I have ordered medications for this patient.” This encounter should be reported with code(s) Diagnosis: Diagnosis: