Assign the ICD-10-CM code(s) according to outpatient coding guidelines (e.g., assign codes to signs and symptoms when a diagnosis has not been established), and assign the CPT evaluation and management code(s) and appropriate modifier(s). Do not assign ICD-10-CM external cause codes. 8. Ms. Hardy was seen in Dr. Stockwell's office. This patient was referred by her primary care physician due to complaints of muscle weakness and diplopia. The consulting physician, Dr. Stockwell, documented a comprehensive history, a detailed examination, and medical decision making of moderate complexity. 9. A patient presented to her family physician's office with the chief complaint of aching muscles. The patient has fibromyalgia and was last seen two months ago for exacerbation of her symptoms. The physician documented a detailed history, a comprehensive examination, and medical decision making of moderate complexity. 10. The attending physician was preparing to discharge a patient for an inpatient hospital stay, during which time the patient's acute bronchitis was treated. The physician examined the patient and reviewed discharge instructions with the patient and the family. The physician also contacted home health services for the patient's continued care. The total time spent discharging the patient was 45 minutes.