Question

As you have previously learned, there are five steps to the assignment E/M CPT codes:

• Step 1: Determine the main term by determining the type of service, place of service, and patient status.
• Step 2: Determine the level of history.
• Step 3: Determine the level of examination.
• Step 4: Determine the complexity of medical decision making.
• Step 5: Determine final code assignment.

ICD-10-CM Diagnosis Coding

First-listed Diagnosis—the condition treated or investigated during the relevant episode of care; coded according to ICD-10-CM. Note: When there is no definitive diagnosis, the primary diagnosis is the main symptom, abnormal findings, or problem.

Secondary Diagnosis—the condition(s) that coexist during the relevant episode of care and affect the treatment provided to the patient; coded according to ICD-10-CM. Note: Assign ICD-10-CM codes to secondary diagnoses only if one or more of the following are documented in the patient’s record: clinical evaluation of the condition, therapeutic treatment of the condition, or diagnostic procedures performed to evaluate the condition

Evaluation and Management 016
HISTORY:
The patient is a 50-year-old white female with history of sudden desaturations in her pulse oximetry recently who had emergency CT scan of the chest done with no signs of pulmonary embolism. She just had bilateral atelectasis that is kind of bordering on pneumonic infiltrate. The patient was not getting up and is not using her incentive spirometry as she should. Even her mother said she should be getting up more and she is inclined to get her up more today even. The patient's incentive spirometry has been haphazardly done according to the nursing staff and she really needs to do this regularly every hour and this was told to the family.
PHYSICAL EXAMINATION:
VITAL SIGNS: The patient's blood pressure 155/81, pulse 98, respirations 18, temperature 37.1. Input 2835 and output 1475.
LUNGS: Clear to auscultation. No E-to-A changes. No dullness to percussion. Normal respiratory effort. Normal chest wall expansion.
HEART: S1 and S2 could be heard without murmur, gallop or rub.
ABDOMEN: Soft, positive bowel sounds, no pain or masses, no hepatosplenomegaly, no abdominal bruits.
EXTREMITIES: Showed no clubbing, cyanosis or edema. Cultures are negative so far of her sputum, but we are waiting on the final on that.
IMPRESSION:
1. Obstructive sleep apnea syndrome.
2. Chronic obstructive pulmonary disease.
3. Atelectasis bordering on pneumonic infiltrate.
4. Restrictive defect.
5. History of seizures.
PLAN:
1. Continue Xopenex q.4h.
2. Incentive spirometry 5 times per hour.
3. Await sputum Gram stain and C and S.
4. Wean oxygen and get her off oxygen, so she can go home off oxygen.
5. CPAP at 8 cm.
I have strongly informed her that she needs to be get up and get moving and she needs to use her incentive spirometry. The patient has been placed on Levaquin p.o. 1 tablet daily and I think she should be on this for 14 days total and continue to dealing with her and hopefully she will improve over time. She probably needs to get another chest x-ray in 2 weeks also and to make sure her lungs have improved. I will see her in the morning.

Answer 1

ICD -10-CM code is the tenth version of international classification of disease and is used by the health care workers and insuranc company people to code a disease and for reimbursement purpose .

ICD code for the following :-

1. Obstructive sleep apnea syndrome - G47.33

2. Chronic obstructive pulmonary disease- J44.9

3. Atelectasis - J98.11