I work on Outpatient Diagnositic coding and I coded too many...Please correct me.
Indications: COPD
Findings: The heart is normal in size and the lungs are free of infiltrate. Findings of obstructive lung disease and chronic interstitial fibrotic change are noted. No masses, infiltrates or other abnormalites are observed. The spine reflects compression of T12 and a previous vertebroplasty at L1. Postsurgical changes are present at the EG junction, apparently for a hiatus hernia. There is evidence of a recurrent hernia. Apical pleural thickening and bleb formation are noted.
Impression:
1. COPD with associated interstitial and peribronchial fibrotic change with no complications.
2. Apical pleural thickening with bleb formation.
3. Status post hernia hernia repair with evidence of recurrent hernia.
4. Osteoporosis with compression of T11 and L1 with post vertebroplasty changes at L1
Final DX:
496
515
511.0
492.0
553.9
733.00
721.2
v45.89
Indications: COPD
Findings: The heart is normal in size and the lungs are free of infiltrate. Findings of obstructive lung disease and chronic interstitial fibrotic change are noted. No masses, infiltrates or other abnormalites are observed. The spine reflects compression of T12 and a previous vertebroplasty at L1. Postsurgical changes are present at the EG junction, apparently for a hiatus hernia. There is evidence of a recurrent hernia. Apical pleural thickening and bleb formation are noted.
Impression:
1. COPD with associated interstitial and peribronchial fibrotic change with no complications.
2. Apical pleural thickening with bleb formation.
3. Status post hernia hernia repair with evidence of recurrent hernia.
4. Osteoporosis with compression of T11 and L1 with post vertebroplasty changes at L1
Final DX:
496
515
511.0
492.0
553.9
733.00
721.2
v45.89
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