Gemini18
Expert
Good Morning, I need assistance with this -
This was coded a 99223, but I get a 99221.
CC: Shortness of Breath
HPI: 67-year old male with a past medical hx of CHF, who was admitted a few months ago for the same complaint. At this time, the pt developed a cough two days prior to admission. He denies fever. At the same time, he also noted some shortness of breath. The shortness of breath increased gradually even at rest. The patient had been noticing leg swelling for a couple of days as well that had been increasing gradually. He denies chest pain, fever, shaking chills, nausea or vomiting, diarrhea or abdominal pain. He came to the ER for further evaluation.
PMHx: HTN, CHF, DM, Arthritis
FMHX: positive for HTN
SHX: denies smoking, alcohol or drug use
PE: Vitals, HEENT, NECK, CV, Resp, ABD, CNS
Labs: X-Rays
Plan: admit to progressive care unit, request Cardio consult, start on Aspirin, Coreg, Sprial CT scan to r/o pulmonary embolus
Assess: Respiratory Distress secondary to CHF exacerbation. Rule out secondary to Pneumonia. Rule out pulmonary embolus
This was coded a 99223, but I get a 99221.
CC: Shortness of Breath
HPI: 67-year old male with a past medical hx of CHF, who was admitted a few months ago for the same complaint. At this time, the pt developed a cough two days prior to admission. He denies fever. At the same time, he also noted some shortness of breath. The shortness of breath increased gradually even at rest. The patient had been noticing leg swelling for a couple of days as well that had been increasing gradually. He denies chest pain, fever, shaking chills, nausea or vomiting, diarrhea or abdominal pain. He came to the ER for further evaluation.
PMHx: HTN, CHF, DM, Arthritis
FMHX: positive for HTN
SHX: denies smoking, alcohol or drug use
PE: Vitals, HEENT, NECK, CV, Resp, ABD, CNS
Labs: X-Rays
Plan: admit to progressive care unit, request Cardio consult, start on Aspirin, Coreg, Sprial CT scan to r/o pulmonary embolus
Assess: Respiratory Distress secondary to CHF exacerbation. Rule out secondary to Pneumonia. Rule out pulmonary embolus