Deck 1: Evaluation and Management Services

Question 1

1-1A INITIAL HOSPITAL CARE ________________________________________
Professional Services: 99221 (Evaluation and Management, Hospital)
ICD-10-CM DX: E10.10 (Diabetes, type 1, with, ketoacidosis), J45.909 (Asthma, asthmatic)

Answer 1

The HPI included a total of 6 elements: location (stomach, legs), quality (persistent vomiting), duration (since 5 AM), timing (continued, recurrent emesis), modifying factors (Humalog × 2, Ultralente), and associated signs and symptoms (confused, cramping in legs, sore throat, abdominal discomfort, emesis), for a level 4 or comprehensive HPI.
The ROS included 10 elements: ophthalmologic (eyes), otolaryngologic (ears and mouth), cardiovascular (cardiac), respiratory (chest), genitourinary, musculoskeletal, neuro-logic, psychiatric, hematologic, and immunologic (infectious disease), for a level 4 or comprehensive ROS.
All 3 of the PFSH (past, family, social history) elements were reviewed for a level 4 or comprehensive PFSH.
A comprehensive HPI (level 4), comprehensive ROS (level 4), and comprehensive PFSH (level 4) place the history level at a level 4 or comprehensive history.
The examination elements include 4 constitutional items (blood pressure, pulse, respi-rations, and general appearance [sluggish]), which equals 1 organ system. There were 2 BAs: neck (supple) and chest (symmetrical). There were 6 OSs: ophthalmologic (eyes), otolaryngologic (ears, mouth), cardiovascular (heart and good pulses), respiratory (clear to auscultation), lymphatic (neck and axillary nodes), and gastrointestinal (abdomen, some tenderness). There were 9 BAs/OSs reviewed, which would ordinarily place this examina-tion in the level 4 or comprehensive physical examination, but for a comprehensive level, only the OSs are counted and the BAs are disregarded.
With a total of 7 OSs, this examination is a level 3 or detailed physical examination. The MDM includes extensive diagnoses/management options, minimal/no data to review, and high risk of death or complication if not treated for a level 4 or high MDM. Ketoacidosis is very serious if left untreated, and there is a high risk of death. At the very minimum, there may be compromises to the brain.
The diabetes is the reason for the care the patient receives (E10.10). The asthma is reported because it is a significant condition (J45.909). The nausea and vomiting are not coded, as they are symptoms of the diabetic condition that was reported as the primary diagnosis.

Question 2

1-1B DISCHARGE SUMMARY __________________________________________
Professional Services: 99238 (Evaluation and Management, Hospital, Discharge)
ICD-10-CM DX: E10.10 (Diabetes, type 1, with, ketoacidosis), E86.0 (Dehydration),
J45.909 (Asthma)

Answer 2

The hospital discharge services are based on the time the physician spends in the final discharge of the patient. The service may or may not include an examination of the patient. Since the physician did not indicate the time spent in discharge of the patient, the low-est level of discharge is reported (99238). Physician education is very important to ensure appropriate reimbursement, since only if the physician records the amount of time can the coder accurately assign a discharge code for a higher level discharge service. The time must be docu-mented in the medical record with the beginning and ending time and the time does not have to be consecutive. The physician may spend time on preparation of the final discharge and then return and spend additional time on the discharge documentation.
The diagnoses are diabetes, dehydration, and asthma, as indicated in the Discharge Diagnosis section of the report. Nausea and vomiting (R11.2) are integral to the disease process (symptoms) and not reported separately. The dehydration is reported separately as it is a dis-tinct condition.

Question 3

1-2A EMERGENCY DEPARTMENT SERVICES______________________________
Professional Services: 99284 (Evaluation and Management, Emergency Department)
ICD-10-CM DX: E86.0 (Dehydration), J02.9 (Pharyngitis), E10.9 (Diabetes, type 1), J45.909 (Asthma), R11.2 (Nausea, with vomiting)

Answer 3

The HPI included 6 elements: location (pharynx and stomach), severity (not eaten anything for the past 2 days), duration (5 days), timing (frequently [running to the bathroom]), modifying factors (taken all insulin shots), and associated signs and symptoms (fever, chills, cough, headache, blood sugar, unable to eat) for a level 4 or comprehensive HPI. The ROS included 10 elements: ophthalmologic (eyes), otolaryngologic (ears), cardiovascu-lar, respiratory (no shortness of breath or heavy breathing), gastrointestinal, genitourinary, neurologic, psychiatric, hematologic, and immunologic (infectious disease) for a level 4 or comprehensive ROS. All 3 elements of the PFSH were noted for a level 4 or comprehensive PFSH. A comprehensive HPI (level 4), comprehensive ROS (level 4), and comprehensive PFSH (level 4) place this history service at a level 4 or comprehensive.
The examination included 4 constitutional elements of blood pressure, pulse, tempera-ture, and general appearance (appears dehydrated with sunken eyeballs and a flushed face) for 1 organ system. There were 2 body areas of neck (supple) and abdomen (soft, nontender). There were 6 organ systems of ophthalmologic (eyes), otolaryngologic (tongue), respiratory (clear to auscultation), cardiovascular (heart, good pulses), lymphatic (neck nodes), and neurologic (normal reflexes). Note that although the thyroid was examined, the endocrine system is not listed as an examination organ system. The endocrine system is listed as an element of the ROS in the history, but not in the examination portion of the service. The total number of BAs/OSs is 9, which would ordinarily make this a level 4 or comprehensive examination; however, only OSs are counted for the comprehensive level. With a total of 7 OSs, this examination is a level 3 or detailed physical examination.
The MDM contained extensive diagnosis/management options (Type 1 diabetes melli-tus that is not controlled, worsening pharyngitis, the new problem of dehydration, stable asthma, and possible ketoacidosis), no data indicated as reviewed, and a high risk to the patient if the condition were left untreated (the diabetes mellitus with complications) for a level 4 or high MDM.
The level of risk is subjective, and some might assign a moderate level of risk rather than a high level of risk to the patient. If a moderate level of risk were assigned, the code would not change from 99284.
The diagnoses are listed in the order as stated on the report in the Impression section, which is dehydration, pharyngitis, diabetes mellitus, and asthma. According to outpatient coding guidelines, you cannot code suspected conditions as if they exist, so the ketoacidosis cannot be reported. You can report present symptoms of nausea and vomiting, as no clear diagnostic state-ment has been made about the cause of the nausea and vomiting.

Question 4

1-3A INITIAL HOSPITAL SERVICE ______________________________________
Professional Services: 99221 (Evaluation and Management, Hospital)
ICD-10-CM DX: R10.31 (Pain[s], abdominal, lower, right quadrant), E10.9 (Diabetes, type 1), J01.90 (Sinusitis, acute), J45.909 (Asthma)

Question 5

1-3B CONSULTATION ________________________________________________
Professional Services: 99253 (Evaluation and Management, Consultation)
ICD-10-CM DX: E10.9 (Diabetes, type 1), R10.31 (Pain[s], abdominal, lower, right quadrant)

Question 6

1-3C RADIOLOGY REPORT ____________________________________________
Professional Services: 76705-26 (Ultrasound, abdomen)
ICD-10-CM DX: R10.31 (Pain[s], abdominal, lower, right quadrant)

Question 7

1-3D RADIOLOGY REPORT ____________________________________________
Professional Services: 71020-26 (X-Ray, Chest)
ICD-10-CM DX: R05 (Cough), R50.9 (Fever)

Question 8

1-4A INITIAL HOSPITAL CARE ________________________________________
Professional Services: 99223 (Evaluation and Management, Hospital)
ICD-10-CM DX: K85.90 (Pancreatitis), R06.02 (Shortness, breath)

Question 9

1-5A INITIAL HOSPITAL CARE ________________________________________
Professional Services: 99223 (Evaluation and Management, Hospital), 99356 (Prolonged service, inpatient) or 99291 (Critical Care Services), 99292 x 3 (Critical Care Services)
ICD-10-CM DX: R00.1 (Bradycardia), T46.0X5A (Table of Drugs and Chemicals, Digoxin, External Cause [T-code], Adverse Effect), T46.5X5A (Table of Drugs and Chemicals, Antihypertensive drug NEC, External Cause [T-code], Adverse Effect), D64.9 (Anemia), I48.91 (Fibrillation, atrial or auricular [established])

Question 10

1-5B PROGRESS REPORT ______________________________________________
Professional Services: 99233 (Evaluation and Management, Hospital)
ICD-10-CM DX: R00.1 (Bradycardia), T46.0X5A (Table of Drugs and Chemicals,
Digoxin, External Cause [T-code], Adverse Effect), T46.5X5A (Table of Drugs and
Chemicals, Antihypertensive drug NEC, External Cause [T-code], Adverse Effect),
D64.9 (Anemia), I48.91 (Fibrillation, atrial or auricular)

Question 11

1-6A PROGRESS REPORT ______________________________________________
Professional Services: 99232 (Evaluation and Management, Hospital)
ICD-10-CM DX: R10.9 (Pain[s], abdominal), E78.1 (Hypertriglyceridemia, essential),
H92.02 (Pain[s], ear)

Question 12

1-7A PROGRESS REPORT ______________________________________________
Professional Services: 99232 (Evaluation and Management, Hospital)
ICD-10-CM DX: N17.9 (Failure, failed, renal, acute), N18.9 (Failure, failed, renal, chronic), D63.1 (Anemia, in, chronic kidney disease), I48.91 (Fibrillation, atrial or auric-ular [established])

Question 13

1-8A PROGRESS REPORT ______________________________________________
Professional Services: 99232 (Evaluation and Management, Hospital)
ICD-10-CM DX: R10.9 (Pain[s], abdominal), E78.1 (Hypertriglyceridemia, essential),
E03.9 (Hypothyroidism), I10 (Hypertension)

Question 14

1-9A DISCHARGE SUMMARY __________________________________________
Professional Services: 99238 (Evaluation and Management, Hospital, Discharge)
ICD-10-CM DX: K26.7 (Ulcer, duodenum/duodenal, chronic)

Question 15

1-10A CONSULTATION ________________________________________________
Professional Services: 99242 (Evaluation and Management, Consultation)
ICD-10-CM DX: I83.812 (Varix, leg, left, with, pain)

Question 16

1-11A CONSULTATION ________________________________________________
Professional Services: 99245 (Evaluation and Management, Consultation)
ICD-10-CM DX: K27.7 (Ulcer, peptic, chronic), F17.210 (Dependence, drug, nicotine, cigarettes)

Question 17

1-12A CONSULTATION ________________________________________________
Professional Services: 99253 (Evaluation and Management, Consultation)
ICD-10-CM DX: N17.9 (Failure/failed, renal, acute)

Question 18

1-12B PROGRESS REPORT ____________________________________________
Professional Services: 99233 (Evaluation and Management, Hospital), 99356 (Evaluation and Management, Prolonged Services)
ICD-10-CM DX: T36.5X5A (Table of Drugs and Chemicals, Gentamicin, External Cause [T-code], Adverse Effect), N17.9 (Failure, failed, renal, acute)

Question 19

1-12C PROGRESS REPORT ____________________________________________
Professional Services: 99233 (Evaluation and Management, Hospital)
ICD-10-CM DX: T36.5X5A (Table of Drugs and Chemicals, Gentamicin, External
Cause [T-code], Adverse Effect), N17.9 (Failure, failed, renal, acute)

Question 20

1-13A CRITICAL CARE ________________________________________________
Professional Services: 99291 (Evaluation and Management, Critical Care), 99292 (Evaluation and Management, Critical Care)
ICD-10-CM DX: T51.0X1A (Table of Drugs and Chemicals, Alcohol, beverage, Poisoning, Accidental [Unintentional]), R06.82 (Tachypnea), F10.229 (Alcohol, intoxication [acute], with dependence), I10 (Hypertension), Z99.11 (Dependence, on, ventilator)

Question 21

1-14A ICU REPORT ________________________________________________
Professional Services: 99291 (Evaluation and Management, Critical Care)
ICD-10-CM DX: I61.1 (Hemorrhage/hemorrhagic, intracranial, intracerebral [nontraumatic], hemisphere, cortical)

Question 22

1-15A CRITICAL CARE ______________________________________________
Professional Services: 99291 (Evaluation and Management, Critical Care), 99292 (Evaluation and Management, Critical Care)
ICD-10-CM DX: I42.6 (Cardiomyopathy, alcoholic), F10.188 (Abuse, alcohol, other specified disorder), I50.9 (Failure/failed, heart, congestive), I27.2 (Hypertension, pulmonary [artery] NEC), N18.9 (Insufficiency, renal, chronic)

Question 23

1-16A CRITICAL CARE, 1-16B PROGRESS REPORT, 1-16C PROGRESS REPORT
Professional Services: 99291 (Evaluation and Management, Critical Care), 99292 × 4 (Evaluation and Management, Critical Care)
ICD-10-CM DX: I46.2 (Arrest/arrested, cardiac, due to, cardiac condition), J96.90 (Failure/failed, respiration/respiratory), N17.9 (Failure/failed, renal, acute), I12.9 (Hypertension/hypertensive, due to, kidney, with, stage 1 through stage 4 chronic kidney disease), N18.9 (Disease/diseased, renal, chronic), J44.9 (Disease/diseased, pulmonary, chronic obstructive), E11.9 (Diabetes, type 2), I95.9 (Hypotension) as indicated on 1-16C, E87.5 (Hyperkalemia) as indicated on 1-16B, Z99.11 (Dependence, on, ventilator)

Question 24

1-17A CRITICAL CARE ADMISSION ____________________________________
Professional Services: 99291 (Evaluation and Management, Critical Care), 99292 × 2 (Evaluation and Management, Critical Care)
ICD-10-CM DX: I95.9 (Hypotension), J96.90 (Failure/failed, respiration/respiratory), I50.9 (Failure/failed, heart, congestive), N17.9 (Failure/failed, renal, acute)

Question 25

1-18A OFFICE VISIT __________________________________________________
Professional Services: 99213 (Evaluation and Management, Office and Other Outpatient)
ICD-10-CM DX: E03.9 (Hypothyroidism)

Question 26

1-19A OFFICE VISIT __________________________________________________
Professional Services: 99203 (Evaluation and Management, Office and Other Outpatient)
ICD-10-CM DX: J06.9 (Infection/infected/infective, respiratory, [acute] upper NOS), R59.0 (Lymphadenopathy, localized)

Question 27

1-19B OFFICE VISIT __________________________________________________
Professional Services: 99213 (Evaluation and Management, Office and Other Outpatient)
ICD-10-CM DX: I88.9 (Lymphadenitis)

Question 28

1-19C CLINIC PROGRESS NOTE ________________________________________
Professional Services: 99213 (Evaluation and Management, Office or Other Outpatient)
ICD-10-CM DX: J06.9 (Infection/infected/infective, respiratory, upper NOS),
J02.9 (Pharyngitis)

Question 29

1-20A OBSERVATION __________________________________________________
Professional Services: 99218 (Evaluation and Management, Hospital Services, Observation Care)
ICD-10-CM DX: E86.9 (Depletion, volume NOS), R19.7 (Diarrhea/diarrheal), E87.2 (Acidosis, metabolic NEC), I12.9 (Hypertension/hypertensive, kidney, with, stage 1 through stage 4 chronic kidney disease), N18.9 (Disease, kidney, chronic), M32.14 (Lupus, nephritis [chronic])

Question 30

1-21A NEWBORN CARE ______________________________________________
Professional Services: 1/1: 99460, 1/2: 99461, 1/3: 99461-25, 1/4: 99461 (Evaluation
and Management, Newborn Care), 1/3: 54150 (Circumcision, Surgical Excision,
Neonate), 1/5: 99238 (Evaluation and Management, Hospital, Discharge)
ICD-10-CM DX: Z38.01 (Newborn, single, born in hospital, by cesarean)

Question 31

1-22A HOSPITAL SERVICES ____________________________________________
Professional Services: 99464 (Newborn Care, Attendance at Delivery), 99468 (Neonatal Critical Care, Initial)
ICD-10-CM DX: P22.0 (Hyaline membrane [disease] [newborn]), P07.17 (Low birth weight, with weight of, 1750-1999 grams), P07.33 (Preterm newborn [infant] gestational age, 30 completed weeks), P71.8 (Hypermagnesemia, neonatal), Z05.1 (Observation [for], suspected, rule out, condition), Z38.01 (Newborn, born in hospital, by cesarean)

Question 32

1-22B NICU PROGRESS REPORT ________________________________________
Professional Services: 99469 (Neonatal Critical Care, Subsequent)
ICD-10-CM DX: P22.0 (Hyaline membrane [disease] [newborn]), P07.17 (Low birth weight, newborn with weight of, 1750-1999 grams), P07.33 (Preterm, newborn [infant] gestational age, 30 completed weeks), P71.8 (Hypermagnesemia, neonatal), Z03.89 (Observation [for], suspected, rule out, condition), Z38.01 (Newborn, born in hospital, by cesarean)

Question 33

1-22C NICU PROGRESS REPORT ________________________________________
Professional Services: 99469 (Neonatal Critical Care, Subsequent)
ICD-10-CM DX: P22.0 (Hyaline membrane [disease] [newborn]), P07.17 (Low birth weight, newborn with weight of, 1750-1999 grams), P07.33 (Preterm newborn [infant] gestational age, 30 completed weeks), P61.0 (Thrombocytopenia/thrombocy-topenic, neonatal, transitory), P59.0 (Jaundice, due to or associated with, preterm delivery), Q25.0 (Patent ductus arteriosus or Botallo's)

Question 34

1-22D NICU PROGRESS REPORT ________________________________________
Professional Services: 99469 (Neonatal Critical Care, Subsequent)
ICD-10-CM DX: P22.0 (Hyaline membrane [disease] [newborn]), P07.17 (Low birth weight, newborn with weight of, 1750-1999 grams), P07.33 (Preterm newborn [infant] gestational age, 30 completed weeks), P61.0 (Thrombocytopenia/thrombocy-topenic, neonatal, transitory), P59.0 (Jaundice, due to or associated with, preterm delivery), Q25.0 (Patent ductus arteriosus or Botallo's)

Question 35

1-23A OFFICE VISIT __________________________________________________
Professional Services: 99395 (Evaluation and Management, Preventive Services)
ICD-10-CM DX: Z00.00 (Examination, medical, general [adult]), E03.9 (Hypothyroidism), E66.3 (Overweight)

Question 36

1-23B OFFICE VISIT __________________________________________________
Professional Services: 99395 (Evaluation and Management, Preventive Services)
ICD-10-CM DX: Z00.00 (Examination, medical [adult]), E03.9 (Hypothyroidism), E66.3 (Overweight)

Question 37

1-23C OFFICE VISIT __________________________________________________
Professional Services: 99395 (Evaluation and Management, Preventive Services)
ICD-10-CM DX: Z02.0 (Examination, medical [adult], admission to, school), E03.9 (Hypothyroidism)

Question 38

1-24A OFFICE VISIT __________________________________________________
Professional Services: 99396 (Evaluation and Management, Preventive Services)
ICD-10-CM DX: Z00.00 (Examination, medical, general [adult]), I10 (Hypertension),
F17.210 (Dependence, drug, nicotine, cigarettes)

Question 39

1-25A OFFICE VISIT __________________________________________________
Professional Services: 99392 (Evaluation and Management, Preventive Services)
ICD-10-CM DX: Z00.129 (Examination, child care [over 28 days old])

Question 40

1-26A OFFICE VISIT __________________________________________________
Professional Services: 99396 (Preventive Medicine, Established Patient)
ICD-10-CM DX: Z01.419 (Examination, gynecological)

Question 41

AUDIT REPORT 1.1 HOSPITAL SERVICES
Incorrect code: 99222

Question 42

AUDIT REPORT 1.2 CONSULTATION
Incorrect code: 99254

Question 43

AUDIT REPORT 1.3 NEUROLOGY CONSULTATION
Incorrect code: 99243

Question 44

AUDIT REPORT 1.4 EMERGENCY DEPARTMENT SERVICES
Incorrect code: 99282

Question 45

AUDIT REPORT 1.5 PROGRESS NOTE SERVICES
Incorrect code: 99232

Question 46

AUDIT REPORT 1.6 CONSULTATION
Incorrect code: 99255
Missing codes: 99356, 99357

Question 47

Case 1-1
LOCATION: Inpatient, Hospital
PATIENT: Mike Bahs
ATTENDING PHYSICIAN: Loren White, MD
CONSULTANT: Timothy Pleasant, MD
REASON FOR CONSULTATION: Rule out neck injury.
HISTORY: This patient is a 17-year-old male who was involved in a motor vehicle accident last night. He remembers driving down the road and the next thing he remembers was trying to reach for his cell phone at a stop sign after the accident. He does not remember any of the details. The car apparently went off the road and hit a tree. The patient is amnesiac for the event but does not believe he lost consciousness. His vehicle was apparently traveling 35-40 miles an hour. There was no report that he was ejected from the vehicle.
PAST MEDICAL HISTORY: He had childhood asthma.
MEDICATIONS: None.
ALLERGIES: None.
FAMILY HISTORY: Noncontributory to the present problem.
SOCIAL HISTORY: He chews tobacco. Alcohol use is rare.
EXAMINATION: Vital signs show he is afebrile. Pulse 64. Blood pressure 110/50. Neurologic: He is awake, alert, and fully oriented. His cranial nerves are grossly intact. HEENT: His extraocular movements are full. His eyes are conjugate. His pupils are equal. His facial strength is intact. On motor examination, he has grossly normal motor strength bilaterally in the upper and lower extremities. His reflexes are normal and symmetric at the biceps, triceps, and brachioradialis. The ankle jerks and the knee jerks are normal and symmetric. Gait is not tested. Sensory examination is grossly intact to light touch. Spine examination: The patient's cervical collar was removed. He has no tenderness to palpation of the cervical spine whatsoever.
The x-rays of the cervical spine, as well as the CT scan of the cervical spine, were reviewed. No fractures or subluxations are noted. CT scan of the head was reviewed, and it is negative for any intracranial pathology.
IMPRESSION/PLAN: In summary, we have a 17-year-old male involved in a motor vehicle accident. He has a mild concussive head injury, as evidenced by his amnesia, and I believe he did lose consciousness for a brief period; however, the exact amount of time for his loss of consciousness is unknown. There is no evidence of any cervical spine injury. The patient is neurologically normal. He does not need to wear a cervical collar. I explained to him and his mother, Gloria, that if the patient develops any weakness, numbness, or tingling in the arms or legs, trouble with his balance, sleepiness, vomiting, weakness of one side of the body, or any other symptoms, they should call their physician immediately.
I want to thank Dr. White for asking me to see this patient.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
1. What items of Review of Systems (ROS) were documented? _________________
2. Under what report heading(s) would the ROS be found? _________________
3. Was the patient the driver or passenger in the motor vehicle? _________________

Question 48

Case 1-2
LOCATION: Inpatient, Hospital
PATIENT: Sorrento Hernandez
PHYSICIAN: Rolando Ortez, MD
CHIEF COMPLAINT: Prematurity with respiratory difficulty.
HISTORY: This is a 30 weeks, 1 day gestation female infant with birth weight of 1808 grams. Mom is a 26-year-old gravida 2, now para 2 mom. Her blood type is O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, HIV negative, GC negative, chlamydia negative, Group B Strep status unknown. Mom's MSAFP was elevated at 14.2 with a 1:180 risk for Down syndrome. No neural tube defect. No amniocentesis performed. She was on prenatal vitamins. First pregnancy went to 35 weeks without complications. He is doing well at 10 years of age; however, he does have Noonan syndrome.
Although this is my first visit, I did attend the delivery of the baby. Spontaneous cry noted, and Apgar score was 7 at 1 minute, with points off for color, tone, and grimace, and then at 5 minutes, Apgar score of 8 with points off for grimace and tone. The infant was then brought back to the NICU for further management. Baby's face does look somewhat dysmorphic with concerns for Noonan syndrome; very small posterior pharyngeal space was noted with difficult intubation, and after several attempts, the anesthesiology department was called and the infant was intubated. Throughout the intubation attempts, standard procedure was followed and the baby tolerated the attempts very well. The intubation was performed because of concerns of hypoventilation noted on exam with decreased breath sounds bilaterally as well as increased work of breathing.
Umbilical artery catheter was also placed without difficulty. First blood sugar did come back at 23, a peripheral IV was placed promptly, and 2 cc/kilo of D10 was given along with placing the infant on D10 at 80 cc/kilo. Second blood sugar has come back elevated. Chest x-ray is obtained, as well as abdominal films, and shows good placement of the UAC at T7, and the endotracheal tube is also in good placement and is a 3.02. The OG has been advanced. The lung fields do show significant granularity present. No pneumothorax, no cardiomegaly. Blood gas is 7.32, PCO² of 50, PO² of 100 and that is on a setting of 22/4, rate of 60% and 80% FIO².
PHYSICAL EXAMINATION: Currently is intubated, her weight is 1808 grams. OFC is 30.5 cm, length is 39.4 cm. Heart rate is in the 130s to 140s. Respiratory rate is at 60 on the ventilator.
O² sat. is in the mid 90s. Blood pressure is right arm, 67/34 with a mean of 46, right leg 67/32 with a mean of 44.
Mild splitting of the cranial sutures is noted along with open posterior and anterior fontanel. Red reflex ×2. Eyes appear to have hypertelorism present and questionable epicanthal folds along with some down-slanting palpebral fissures. Ears appear to be low set and posteriorly rotated. Palate is intact. There is a small retropharyngeal space. Clavicles are intact. I do not appreciate any webbing on the neck. Nipples, questionable, mildly wide spaced. Lungs at this time are clear to auscultation. She has good symmetric aeration; minimal chest rise noted. Prior to that, lungs were remarkable for decreased aeration with crackles. Heart is regular rate and rhythm, no murmurs noted. Femoral pulses palpable, cap refill less than 2 seconds. Abdomen is without hepatosplenomegaly, three-vessel cord. Genitourinary: Normal female. Extremities: Adequate range of motion, no contractures or hip abnormalities noted. Skin is ruddy in complexion. Neurologic Exam: Hypotonia diffusely.
Developmental assessment: No breast buds, soft pinna with minimal recoil, no creases on the feet, consistent with a 30-week preterm infant.
IMPRESSION
1. Premature female infant.
2. Respiratory distress due to hyaline membrane disease as well as a component of hypoventilation secondary to maternal elevated magnesium.
3. Observation for sepsis.
4. Maternal hypermagnesemia with elevated magnesium in the infant as well.
5. Family history of Noonan syndrome in an older brother.
PLAN: Admission to the NICU. Intubation has been performed, and she is on mechanical ventilation. Will go ahead with the surfactant therapy per protocol, close cardiorespiratory monitoring and monitoring of blood gases and chest x-rays. NPO status, and she will be on D10 with 0.94 mEq of calcium gluconate added to run at 80 cc/kilo/day. Ampicillin and gentamicin administered per protocol. Blood cultures have been obtained as well as a CBC, magnesium level, and further glucose monitoring. She will also need chromosomal testing, and that will be drawn in the near future. Also, head ultrasound at 6 days of life will need to be performed. I have not talked with the mother. Her condition has deteriorated post cesarean section and she is not available at this time. I have talked in detail with the father in regard to the above, including possibility of further deterioration prompting transfer to another facility. All of his questions have been addressed.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
1. Was this the initial or subsequent visit? _________________
2. Does the age of the patient affect CPT code selection? _________________
3. What two factors affect diagnosis code assignment? _________________