Coding challenge :)

hthompson

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I know how I code it, but I wanted to bouce it off all of you and see if I'm in the majority.

Pt has DMII and COPD and has a "daily" standing order to come in and have temp, pulse, resp rate, BP, blood glucose, pulse ox monitored and then receive Xopenex 1.25mg followed by Atrovent .5mg and then have pulse ox and occasionally resp rate re-checked and then is D/C home.

The chart note from the RN states "last home tx 0730, states he is starting to feel "plugged up" "stuff coming up".
Temp
Pulse
Resp rate
BP
Pulse ox
Glucose - 3*PP
Notes 4 allergies
Xopenex 1.25mg started via neb 1040
Atrovent 0.5mg started via neb 1054
Resp rate after tx 30
02 sat 91% RA
states "he can breath"
signed off by RN

How would you code this?

E/M? Procedure codes? Drugs? Diagnoses?

Thanks in advance for the insight!!
 
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