Martin Kilner, a 15-year-old male, presented to Dr. Yearling complaining of a cough and a sore throat, lasting about 1 week. He and his mother deny fever, nasal congestion, or runny nose. He

PATIENT: KILNER, MARTIN
ACCOUNT/EHR #: K018-081365997
DATE: 08/11/18

Attending Physician: Norman Yearling, MD

Martin Kilner, a 15-year-old male, presented to Dr. Yearling complaining of a cough and a sore throat, lasting about 1 week. He and his mother deny fever, nasal congestion, or runny nose. He says he feels more tired than usual and his mom states that he hasn’t been getting out of bed to go to camp or any other activities. Mom seems most worried that he is much less active than he usually is and that he has been hanging out with his friends until late at night. Patient states that his “mom won’t get off my back.” He admits that his grades had been dropping before summer break, and he quit the baseball team. Mom leaves the room, and patient admits to smoking pot every day, usually several times a day, for the last 8 or 9 months or so. He denies any other drug use and states smoking pot is “no big deal.”

After discussion with the patient and his parents, Martin is admitted into a one-week substance abuse residential treatment program for daily individual and group behavioral counseling.

Upon admission:
PE: Physical examination is remarkable only for a mildly erythematous throat without petechiae. Lungs are slightly congested, and the rest of his exam is normal. Vital signs are also unremarkable. A rapid strep screen is negative.

FIRST DAYINDIVIDUAL COUNSELING: Discussion with patient about side effects and risks of abusing pot. He states he has tried to quit but can’t make it through an entire day without smoking. It is pointed out to him that his pot use is already having a negative impact on his life (his absence and lack of interest in school). He understands that his parents need to know about this, but that he must tell them himself. He is assured that doctor-patient confidentiality is secure. We discussed options and methodologies for him quitting with reduced effects. Blood is taken to record the levels of THC, and he agrees to regular surveillance.

Dx: Marijuana abuse behavioral counseling; daily individual counseling, daily group counseling. Re-evaluation after six (6) full days of residential treatment.
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One ICD-10-CM diagnosis code
Two PCS procedure codes
Neither one starts with 0.
You may have to try switching the order of the codes to get them to fit in Connect. In this case, either procedure could be considered the principal procedure.