Sleep Apnea Diagnosis

mikesyzf

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Issue: Physician is a specialist. Physician is asked, in consultation, to “evaluate for possible sleep apnea”
I am confused what the Dx. Should be.
The problem is listed in the Assessment/Plan:
-The Specialist’s consultation note has several diagnoses listed, with none of them being sleep apnea.
-Listed just below that is what looks like templated “Obstructive Sleep Apnea” with the referral for a sleep study.

I searched online if Sleep apnea can be the Dx. even if the pt. has not been tested for it yet.

I found a flow chart for “Sleep apnea diagnosis”. After going through symptoms such as snoring, Epworth sleep scale score, daytime sleepiness etc. the flow chart then states “Refer for Diagnostic Study to confirm diagnosis of Sleep Apnea”. It looks like Sleep Apnea can be the diagnosis even though a study has not been done yet.

I’m trying to see if I could code this as it. I know it’s not a very good note, and that I really should query the Physician.
Below is the note:

I'm seeing Patient in request of Dr. XXXXXX to evaluate for possible sleep apnea.
Patient states that she has had a history of waking up short of breath and gasping. This happens in all positions. She feels tired during the day. She believes that multiple family members have sleep apnea, though no one is on CPAP machine currently. She does have acid reflux which she takes ranitidine. She does wake up with headaches at times. She also wakes up with dry mouth at times. the most she has ever weighed is 20, 98 pounds. Her ESS is 0 out of 24.

ROS: Additionally reports: significant for GERD, dry skin, menstrual pain, she does take zolpidem for insomnia; otherwise negative review of systems

Physical Exam :
Patient is a 30-year-old female
Constitutional: General Appearance: morbidly obese. Level of Distress: NAD. Ambulation: ambulating normally.
Head: Head: normocephalic and atraumatic.
ENMT: Nose: no lesions on external nose, septal deviation, sinus tenderness, or nasal discharge and nares patent. Lips, Teeth, and Gums: no mouth or lip ulcers or bleeding gums and normal dentition. Oropharynx: no erythema or exudates and moist mucous membranes, tonsils not enlarged, and Oropharynx: Structures Visualized (Mallampati Classification): Class 4.
Neck: Neck: FROM, trachea midline, and no masses. Lymph Nodes: no cervical LAD, supraclavicular LAD, axillary LAD, or inguinal LAD. Thyroid: no enlargement or nodules and non-tender.
Lungs: Auscultation: no wheezing, rales/crackles, or rhonchi and breath sounds normal, good air movement, and CTA bilaterally.
Cardiovascular: Heart Auscultation: normal S1 and S2; no murmurs, rubs, or gallops; and RRR. Neck vessels: no carotid bruits.
Abdomen: Bowel Sounds: normal. Inspection and Palpation: no tenderness, guarding, masses, rebound tenderness, or CVA tenderness and soft and non-distended.
Musculoskeletal: Joints, Bones, and Muscles: no tenderness or bony abnormalities and normal movement of all extremities. Extremities: no cyanosis, edema, varicosities, or palpable cord.
Neurologic: Gait and Station: normal gait and station.

Assessment / Plan
1.–History of snoring and gasping at night associated with nonrestorative sleep; she is morbidly overweight; she has a Mallampati 4 airway. I suspect she has sleep apnea.
2.–Acid reflux for which she is on ranitidine.
3–C–section.
4. Obesity.
5–menstrual pain.
6–dry skin
1. Obstructive sleep apnea of adult
G47.33: Obstructive sleep apnea (adult) (pediatric)
2. Obstructive sleep apnea syndrome
G47.33: Obstructive sleep apnea (adult) (pediatric)
•SPLIT NIGHT SLEEP STUDY REFERRAL - Schedule Within: provider's discretion Note to Provider: Split
A copy of this report was given to Physician XXXXX
 

Coder85

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In the absence of a definitive diagnosis you may code the symptoms and family history.
 
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