Health Information ManagementDiscussion postMedical coding

NU673: CPT E and M code and ICD-10 for a new patient

A discussion determining which CPT evaluation and management code and which ICD-10 diagnosis codes to assign for a new patient encounter involving a full physical and psychiatric intake on a 22 year old presenting with depressive symptoms, avoidance and physical anxiety symptoms, justifying the code through the medical decision making complexity approach by counting diagnoses and management options, assessing the amount and complexity of data reviewed and identifying the level of risk, and exploring how the assigned ICD-10 codes affect third party payor reimbursement.

Aug 13, 2026

Editorial process

Last reviewed · August 13, 2026

Written by

Aaron Bishop

MA, Education

assignment interpretation and research-methods coaching across disciplines

Reviewed by

Dr. Nathan Cole

PhD, Rhetoric & Composition

Argumentation and thesis development

On this page

Interpret the task
Assignment instructions
Deliverables
Proposed outline
Research plan
Reference shortlist
Final review

Complexity, not time

The prompt tells you which method to use and that instruction is the whole assignment. Evaluation and management levels may be selected either by medical decision making or by total time, and you are told to use the complexity approach, so a post that reaches its code by counting how long the visit took has answered a different question. Medical decision making has three components and the level is set by meeting two of the three: the number and complexity of problems addressed, the amount and complexity of data reviewed or analysed, and the risk of complications, morbidity or mortality from the patient's management. Work through all three explicitly and then say which two carried the level, because that final sentence is the justification the prompt asks for and it is the part most posts leave out even after doing the analysis correctly. Do the three-element analysis in writing rather than in your head, since the working is what is marked.

Take the three elements in order against what the case actually contains. On problems, a new presentation of a condition requiring assessment sits differently from a stable established one, and here you have a probable social anxiety disorder identified as the primary treatment target alongside depressive symptoms, which is more than one problem and neither is stable. On data, be honest: the vignette gives you a history, vital signs, a physical examination and a mental status examination, but no laboratory results, no imaging, no external records obtained and no discussion with another professional. Examination findings are not data under this element, which is a distinction that catches people out. On risk, weigh the management being contemplated and the patient's own risk, including whether the presentation raises any question requiring assessment, since that materially changes the risk level. Say what would have raised the data element had it been present, because that shows you understand the criterion.

The coding decision itself should be reasoned, not asserted, and the reasoning is what earns marks even where reasonable coders would differ. Say which new patient office visit level you are assigning, show how two of the three elements support it, and note where a different reading would move it one level either way. Two practical points are worth making. New patient codes require all three key components at their level under the older framework and are selected on decision making or time under the current one, so state which framework you are applying and stay consistent with it. And the case explicitly involves both a full physical and a psychiatric intake in one encounter, which raises a real question about whether one code captures the work, and saying so demonstrates understanding rather than confusion. Stating the ambiguity is stronger than pretending the case is cleaner than it is.

The diagnosis coding needs the same care and has its own traps. Sequence matters: the code representing the primary reason for the encounter goes first, and the prompt tells you the provider identified social anxiety disorder as the primary treatment target, which points the sequencing. Code what is documented and supported rather than what is suspected, and resist coding a formal depressive disorder if the documentation supports symptoms rather than a diagnosis, since symptom codes exist for that reason. Note also that the record contains a body mass index consistent with obesity and a blood pressure reading, and think about whether either is documented and addressed sufficiently to be coded at this encounter. That question, rather than the primary diagnosis, is where the interesting coding judgement in this case actually lies. Say what documentation would be needed before either could properly be reported. Sequencing follows the documentation, not the severity.

The reimbursement half is a separate question and deserves its own paragraph rather than a closing sentence. Diagnosis codes establish medical necessity for the service billed, so the link between the diagnosis and the evaluation and management level is what a payor examines; a high-level code supported by a single uncomplicated diagnosis invites denial. Behavioural health adds specific complications: coverage carve-outs to separate benefit managers, parity requirements, and rules that limit billing a physical and a psychiatric service on the same day. Say what would happen to this claim in practice. On execution, cite the coding guidelines and payer sources rather than a coding blog, use peer-reviewed evidence where the prompt asks for it, follow APA in text, and check the rubric, since collaboration points are forfeited if the two peer responses do not meet the stated requirements. Read the rubric once before posting and once before replying, since the two carry separate marks.

Likely learning objectives

Inferred from the brief — check these against your own rubric.

01
Select an evaluation and management level by medical decision making rather than time.
02
Apply all three decision making elements and identify which two set the level.
03
Distinguish examination findings from data reviewed.
04
Sequence diagnosis codes by the primary reason for the encounter.
05
Code what is documented rather than what is suspected.
06
Explain how diagnosis codes establish medical necessity for reimbursement.

Assignment instructionsQuoted verbatim

Read the full question

Review every instruction before using the planning guidance that follows.

NU673-7D Unit 7 DQ 1 Discussion Prompt Use your lecture materials to determine what CPT E&M Code and ICD-10 diagnosis code to utilize for this ‘new patient’ encounter using the medical decision-making (complexity) approach. Provide justification for the code you assigned by including the following information in your discussion: Case: This patient presents to a local health center. As the provider, you must conduct a full physical on the patient as well as a psychiatric intake. Liam is a 22-year-old who reports to you that he feels depressed and is experiencing a significant amount of stress about school, noting that he’ll “probably flunk out.” He spends much of his day in his dorm room playing video games and has a hard time identifying what, if anything, is enjoyable in a typical day. He states once he leaves the room he begins sweating and feels as if he has heart palpations. He rarely attends class and has avoided reaching out to his professors to try to salvage his grades this semester. Liam has always been a self-described shy person and has had a very small and cohesive group of friends from elementary through high school. Notably, his level of stress significantly amplified when he began college. You learn that when meeting new people, he has a hard time concentrating on the interaction because he is busy worrying about what they will think of him – he assumes they will find him “dumb,” “boring,” or a “loser.” When he loses his concentration, he stutters, is at a loss for words, and starts to sweat, which only serves to make him feel more uneasy. After the interaction, he replays the conversation over and over again, focusing on the “stupid” things he said. Similarly, he has a long-standing history of being uncomfortable with authority figures and has had a hard time raising his hand in class and approaching teachers. Since starting college, he has been isolating more, turning down invitations from his roommate to go eat or hang out, ignoring his cell phone when it rings, and habitually skipping class. His concerns about how others view him are what drive him to engage in these avoidance behaviors. After conducting your assessment, you give the patient feedback that you believe he has social anxiety disorder, which should be the primary treatment target. You explain that you see his fear of negative evaluation, and his thoughts and behaviors surrounding social situations, as driving his increasing sense of hopelessness, isolation, and worthlessness. Significant Symptoms: Anxiety Depression Ruminations Social Anxiety Physical symptoms; sweating, heart palpations Vitals: 127/80 98 18 60 90% BMI 30 225 lbs 72” Physical exam: General: Well appearing, well-nourished, in no distress. Oriented x 3, normal mood and affect. Ambulating without difficulty. Skin: Good turgor, no rash, unusual bruising, or prominent lesions Hair: Normal texture and distribution. Nails: Normal color, no deformities HEENT: Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring. Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi have normal optic discs and vessels, no exudates or hemorrhages Ears: EACs clear, TMs translucent & mobile, ossicles nl appearance, hearing intact. Nose: No external lesions, mucosa non-inflamed, septum, and turbinates normal Mouth: Mucous membranes moist, no mucosal lesions. Teeth/Gums: No obvious caries or periodontal disease. No gingival inflammation or significant resorption. Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged and non-tender Heart: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop Lungs: Clear to auscultation and percussion Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia Back: Spine normal without deformity or tenderness, no CVA tenderness Rectal: Normal sphincter tone, no hemorrhoids or masses palpable Extremities: No amputations or deformities, cyanosis, edema or varicosities, peripheral pulses intact Musculoskeletal: Normal gait and station. No misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal strength or tone in the head, neck, spine, ribs, pelvis or extremities. Neurologic: CN 2-12 normal. Sensation to pain, touch, and proprioception normal. DTRs normal in upper and lower extremities. No pathologic reflexes. Psychiatric: Oriented X3, intact recent and remote memory, judgment and insight, anxious mood and affect. Breast: No nipple abnormality, dominant masses, tenderness to palpation, axillary or supraclavicular adenopathy. G/U: Penis circumcised without lesions, urethral meatus normal location without discharge, testes and epididymides normal size without masses, scrotum without lesions. The level of medical complexity encompassed by including the number of points for the diagnoses/management options and the amount/complexity of data reviewed; then identify the level of risk for complications, morbidity, mortality In the discussion explore how the ICD-10 Codes that you assigned impact third-party payor reimbursement for this visit. Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position. Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format. Please review the rubric to ensure that your response meets the criteria. NU673-7D Unit 7 DQ 1 Estimated time to complete: 2 hours Discussion Peer/Participation Prompt Please respond to at least 2 of your peer’s posts with substantive comments using the following steps: Substantive comments add to the discussion and provide your fellow students with information that will enhance the learning environment. References and citations should conform to APA standards. Remember: Please respect the opinions of others, even if their views differ. In other words, disagree professionally and respectfully. Plagiarism is never acceptable – give credit when credit is due – cite your sources. Responses need to address all components of the question, demonstrate critical thinking and analysis, and include peer-reviewed journal evidence to support the student’s position. Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format. Please review the rubric to ensure that your response meets the criteria. Collaboration points will be forfeited if you fail to meet the response post guidelines.

Course-wide instructions that accompany this question

ADDITIONAL INSTRUCTIONS FOR THE CLASS Discussion Questions (DQ) Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses. Weekly Participation Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. APA Format and Writing Quality Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition. Use of Direct Quotes I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. LopesWrite Policy For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. Late Policy The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading. Communication Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

Turn the brief into deliverables

01
The CPT evaluation and management code for this new patient encounter.
02
The ICD-10 diagnosis codes assigned.
03
Justification through the number of diagnoses and management options and the amount and complexity of data reviewed.
04
An identification of the level of risk of complications, morbidity or mortality.
05
An exploration of how the assigned ICD-10 codes affect third party payor reimbursement.
06
Peer-reviewed evidence, APA citations, and two substantive peer responses.

Three elements, then the codes

Method

Why medical decision making rather than time, and which framework applies.

Problems addressed

How many, how complex, and whether stable or newly presenting.

Data reviewed

What the encounter actually generated, and what it did not.

Risk

Management contemplated and patient risk, including any safety question.

The level assigned

Which two elements carried it, and where a different reading would move it.

Diagnosis codes

What is documented, what is supported, and the sequencing.

Secondary findings

Whether the body mass index or blood pressure reading is codable here.

Reimbursement

Medical necessity, behavioural health carve-outs and same-day billing limits.

Guidelines and payer rules

Recommended databases

Current evaluation and management documentation guidelines
ICD-10-CM official guidelines for coding and reporting
Payer coverage and behavioural health policy documents
PubMed for peer-reviewed evidence

Search sequence

1.
Read the current medical decision making table before assessing the case against it.
2.
Confirm which framework your course is teaching, since the rules changed.
3.
Check the ICD-10 guidance on coding symptoms rather than unconfirmed diagnoses.
4.
Look up the sequencing rule for the principal reason for an encounter.
5.
Find payer guidance on same-day physical and behavioural health billing.

Reference shortlist

These are authoritative starting points, not a ready-made bibliography. A qualified reviewer must confirm that each source fits the assignment and supports the claim beside which it is cited.

Nothing here is cleared for citation until you have read it.

01
Social Anxiety Disorder
StatPearls, NCBI Bookshelf · 2023
The diagnostic criteria the documentation has to support before the condition can be coded as the primary diagnosis.
02
Evaluation and Management Visits
Centers for Medicare & Medicaid Services · 2025
The payer's own statement of how evaluation and management levels are determined, which is the criterion the post must apply.
03
ICD-10-CM
National Center for Health Statistics, CDC · 2025
Official coding guidance, including the rules on coding symptoms rather than unconfirmed conditions and on sequencing.
04
Informed Consent
StatPearls, NCBI Bookshelf · 2023
Documentation as the basis for what may be billed, which is the principle underlying the medical necessity argument.

Review before submission

Common mistakes

Selecting the level by time when the prompt specifies complexity.
Applying the three elements without saying which two set the level.
Counting the physical examination as data reviewed.
Failing to state which coding framework is being applied.
Coding a formal depressive disorder where documentation supports symptoms.
Ignoring the body mass index and blood pressure findings entirely.
Sequencing the diagnosis codes without reference to the primary treatment target.
Treating reimbursement as a closing sentence rather than a required element.
Citing coding blogs instead of guidelines or payer sources.

Submission checklist

The medical decision making approach is used and named.
Problems addressed are counted and their complexity assessed.
Data reviewed is assessed honestly, noting what the vignette does not contain.
Risk of complications, morbidity or mortality is identified with reasoning.
The two elements that set the level are named explicitly.
The coding framework being applied is stated and used consistently.
The combination of a full physical and psychiatric intake in one encounter is addressed.
Diagnosis codes are sequenced by the primary reason for the encounter.
Only documented and supported conditions are coded.
Whether the body mass index or blood pressure should be coded is considered.
Medical necessity is explained as the link between diagnosis and service level.
Behavioural health coverage complications are addressed.
Guidelines and payer sources are cited in APA, with two peer responses posted.

Use this guide to plan and review your own work. Follow your institution's rules and read our academic-integrity policy.