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cpt code for A DTP and an oral poliomyelitis vaccine (live) are administered to a new 10-year-old patient. A problem focused history and examination are performed for an acute URI, and the medical
decision making is straightforward (separate identifiable service).
S: Patient is here today with fatigue and chest congestion, S/P MI 3 yrs ago, homebound, takes insulin for DMII, & wonders if she has pneumonia O: Pt appears alert, oriented, no acute distress. [ Wears glasses, due for eye exam, ear canals patent w/no wax present. Nasal mucosa inflamed, pharynx slightly red, thyroid not enlarged. Chest wheezy w/rales. There is +2 bilateral lower extremity
Documented in Medical Record: Reported on Claim: Required for Risk Adjustment: Primary ICD-9-CM code: 487.1 Acute URI w/Flu 487.1 Yes Secondary ICD-9-CM code: 250.70 DM2 w/manifestation 250.70 Yes Tertiary #3 ICD-9-CM code: 707.06 Ulcer 707.06 Yes Tertiary #4 ICD-9-CM Chest wheezy w/rales. There is +2 bilateral lower extremity edema due to vascular disease, and L ankle decubitus ulceration due to DM. A: Acute upper respiratory infection with Flu 487.1 Diabetes mellitus with peripheral circulatory disorders type ii or unspecified type not stated as uncontrolled 250.70 Ulcer 707.06 CHF 428.0 ASCVD 414.00 P: Chest x-ray performed, counseled patient to force fluids, bed rest, and return to clinic if not improved. DM, ulcer, edema: stable, no changes to meds. CHF and ASCVD: stable:no changes to meds ]
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Asked 10/3/2012 2:05:19 PM
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