Review the following case and assign CPT/HCPCS and ICD-10-CM codes Patient Encou
ID: 241866 • Letter: R
Question
Review the following case and assign CPT/HCPCS and ICD-10-CM codes
Patient Encounter Notes New patient with a common cold CC : Sore throat HPI : Patient is a 74 year old male who presents with a sore throat which began three days ago. ROS : Negative for fevers or chills; positive for mild malaise Physical Exam General appearance: No acute distress; conversant Vitals: 98.6, 72, 20, 110/74 HEENT: Oropharynx is clear with no mucosal ulcerations; normal posterior pharynx without erythema or exudate. External auditory canals patent with pearly TMs Lungs: CTA with normal respiratory effort and no intercostal retractions Assessment Viral URI, Push fluids, Tylenol as needed, Rest Return to clinic if no improvement in 7 to 10 days
Explanation / Answer
2018 ICD-10-CM Diagnosis Code J06.9
Acute upper respiratory infection, unspecified
Applicable To
The following code(s) above J06.9 contain annotation back-references
that may be applicable to J06.9:
Diseases of the respiratory system
Acute upper respiratory infections
Acute upper respiratory infections of multiple and unspecified sites
Approximate Synonyms
References:
http://www.icd10data.com/ICD10CM/Codes/J00-J99/J00-J06/J02-/J02.9
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