Question

LOCATION: Hospital Emergency Department PATIENT: Kristie Mooney PHYSICIAN: Paul Sutton, M.D. CHIEF COMPLAINT: Generalized abdominal pain. SUBJECTIVE: This is a 31-year-old white female who has history of hypertension and is on Hyzaar. No other significant ongoing medical problems, taking no other medication. No known allergies. LMP three weeks ago. Denies being sexually active. She presents to the Emergency Room with a history of generalized abdominal pain, but more prominently in the right upper quadrant, that started suddenly this evening at about 6:00 p.m. She had some nausea but no vomiting. She had some chills. Felt dry-mouthed and weak. She described the discomfort as such that she could not get comfortable and needed to keep moving around. She describes it as sharp and intermittent in its intensity and feels discomfort into her back as well. She has taken Gas-X and Ex-Lax, etc. and it has not afforded any relief. She states about a month ago she had a similar episode but not as intense. REVIEW OF SYSTEMS: CONSTITUTIONAL: She denies significant fevers, sweats, or chills within the last 24 to 48 hours. She did have some of that about a week ago, however. GI: The nausea, but no vomiting or diarrhea, as outlined above. GU: No urgency, frequency, or dysuria. No significant cough or shortness of breath. CARDIOVASCULAR: No chest pain or peripheral edema. OBJECTIVE: She is afebrile. RESPIRATORY RATE: 16. PULSE: 100. BLOOD PRESSURE: 154/116. She is in obvious discomfort with abdominal pain. HEENT EXAM is grossly unremarkable. Neck: No thyromegaly, no adenopathy, no venous distention. HEART: There is S1-S2, no S3 or S4. The rhythm is regular. The LUNGS sounds are clear. No CVA tenderness. ABDOMEN: Obese, bowel sounds present and active. No organomegaly, masses, or hernias noted. She has exquisite tenderness in the epigastrium but more prominently in the right upper quadrant and is felt to have a positive Murphy's sign. EXTREMITIES: Negative for cyanosis or edema. RADIOLOGY STUDY: Flat and upright of the abdomen showed no significant dilated loops of bowel, no air fluid levels. No free air. I did not identify any calcifications in the right upper quadrant. LABORATORY STUDIES: Amylase and lipase are both unremarkable. Liver panel: Alkaline phosphatase is normal at 128, total bilirubin is elevated, however, at 1.8 with a direct at 1.1. She has an SGOT elevation at 482, high normal at 42 and an SGPT at 282, high normal at 65. A CBC and basic metabolic panel are pending. IV access is obtained. She was given 60 mg of IM Toradol which afforded rather significant improvement in her discomfort, although did not resolve her pain. ASSESSMENT: 1. Abdominal pain, R/O Cholecystitis. 2. Abnormal liver function as outlined above, and bilirubin disorder. PLAN: Contact Family Medicine Physician taking calls, was notified regarding this patient and we discussed the case with him. She is subsequently admitted for further evaluation and treatment.

What are the codes for CPT, ICD-10-CM and HCPCS?

Answer 1

ICD -10-CM code is the tenth classification of diagnosis and is used by the healthcare workers to code a diagnosis . It is also used by the insurance company to code for reimbursement purpose .

ICD -10-CM code for :-

Hypertension - I10

Abdominal pain right upper quadrant - R10.11

Cholecystitis - K81

CPT code is the current procedural terminology . It is used to code a procedure . Healthcare workers and insurance company uses thess codes to represent the procedure .

CPT code for :-

LFT - 80076

CBC - 85027