seayres@yahoo.com
Guest
I am questioning the coding of the attached note. Can someone please look at the note and give me your opinion? I feel there may be an element of medical necessity.
Thanks!
Progress Notes
Chief Complaint
Patient presents with
• Cough
x 1 week
HPI:
is here today with his father due to cough he has had for about 1 week. He said no congestion or runny nose. He has no history of asthma. He does not use tobacco. He has had no significant fever. He is drinking and eating well. He is not having difficulty sleeping. No difficulty breathing. Is able to play basketball without much difficulty or cough.
PHE:
BP 104/64 (SITE: right arm, Orthostatic Position: sitting, Cuff Size: regular) | Temp 36.7 °C (98.1 °F) (Temporal) | Ht 1.689 m (5' 6.5") | Wt 68.3 kg (150 lb 8 oz) | BMI 23.93 kg/m²
Alert no acute distress. Sclera clear he has no eye discharge. Tympanic membranes clear bilaterally. Oropharynx clear moist his membranes. Nose is clear discharge. Chest is clear and unlabored throughout without prolonged expiration or wheezing. Is regular rate and rhythm. He has no significant cervical lymphadenopathy.
Impression/Plan:
ICD-10-CM
1. Cough R05
Father was reassured. Asked him to drink plenty of fluids and call if symptoms worsens at all especially if he develops fever. I suspect this is likely viral in nature and just needs some more time. Did not see reason to put him on antibiotics at this time without any significant nasal symptoms.
Thanks!
Progress Notes
Chief Complaint
Patient presents with
• Cough
x 1 week
HPI:
is here today with his father due to cough he has had for about 1 week. He said no congestion or runny nose. He has no history of asthma. He does not use tobacco. He has had no significant fever. He is drinking and eating well. He is not having difficulty sleeping. No difficulty breathing. Is able to play basketball without much difficulty or cough.
PHE:
BP 104/64 (SITE: right arm, Orthostatic Position: sitting, Cuff Size: regular) | Temp 36.7 °C (98.1 °F) (Temporal) | Ht 1.689 m (5' 6.5") | Wt 68.3 kg (150 lb 8 oz) | BMI 23.93 kg/m²
Alert no acute distress. Sclera clear he has no eye discharge. Tympanic membranes clear bilaterally. Oropharynx clear moist his membranes. Nose is clear discharge. Chest is clear and unlabored throughout without prolonged expiration or wheezing. Is regular rate and rhythm. He has no significant cervical lymphadenopathy.
Impression/Plan:
ICD-10-CM
1. Cough R05
Father was reassured. Asked him to drink plenty of fluids and call if symptoms worsens at all especially if he develops fever. I suspect this is likely viral in nature and just needs some more time. Did not see reason to put him on antibiotics at this time without any significant nasal symptoms.