LOCATION: outpatient, clinic PATIENT: Dolly Lee PRIMARY CARE PHYSICIAN: Frank Ga
ID: 192844 • Letter: L
Question
LOCATION: outpatient, clinic PATIENT: Dolly Lee PRIMARY CARE PHYSICIAN: Frank Gaul, M.D SUBJECTIVE: Dolly comes in for two concerns, First is a recent prominent cough with a sore throat. Cough is productive at times and complains of fever and chills as well. The second concern s the patient is in for recheckon depression. She has noticed no improvement of problems since starting the Zolooft, and has been on 50 mg for two weeks and 25 mg the first week. OBJECTIVE: On eam weight is 220. Pulse is 84. R is 16. The patient , is NAD. Fundi: Benign. PERRLA, normal EOMs. TMs are benign. Pharynx is slightly erythematous. Neck is benign. No anterior or posterior nodes. Heart is S1-S2. Lungs are clear. ASSESSMENT: 1. Acute Bronchitis with probable pharyngitis. 2. Manic depressive episode. PLAN:We will continue Dolly on the 50mg dose and six-week samples were given. We will see her back n six weeks, and if not markedly improved we will consider swetching to 100mg dose at that time. If she should have any problems in the meantime, she will call or return to the clinic. I placed on her amosicillin 500 mg t.i.d times 10 days for pharyngitis and bronchitis symptoms. she will push fluids, and she will use Robitussin AC if need be for dry cough with apropriate precautions and follow up for this if not improving also. what are the CPT, ICD-10-CM AND HCPCS code use for this simulation?
Explanation / Answer
CPT -> The code set is used by the providers so that they can report medical procedures. In case of outpatient settings (such as when a visiting physician attends an inpatient) it is used to report professional services furnished. This code is maintained by The American Medical Association.
ICD-10-CM -> ICD-9-CM which was used to report medical diagnosis has now been replaced by this code. The code ICD-10-CM is now used by all providers in U.S. healthcare settings. Based on the patient's medical record documentation codes are selected by the providers. This code is maintained by CDC.
HCPCS -> For this code set the CPT codes are level I modifiers. The level II codes and modifiers are important for identifying products, supplies as well as services which were not covered in level I. These may include ambulance services, durable medical equipment and devices.
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