Prescription refill of lisinopril

Coding Assignment . History of Present Illness: The patient is a 45-year-old female who is coming in for a prescription refill of lisinopril. She has been compliantly taking this medication for several years and denies any side effects (i.e. cough). She has been hypertensive for 15 years, following her third pregnancy.

Past Family/Social History: n/a
Review of Systems: Denies any CP, SOB, or leg swelling

Physical Exam: 

BP 134/84 Pulse 80 and regular

Assessment 

1. _____________. (need ICD coding number here)

Plan 

1. Continue on same dose – refill sent to pharmacy of patient’s choice
2. Total time spent with patient 10 minutes

CPT ____________ (CPT coding number here).

Thank you for your helping!