I am having a hard time coding this office visit as anaphylaxis, which provider has given as diagnosis. We are told to code what providers give as diagnosis, but we are also told to help them choose code that best reflects the documentation. Please tell me how you would code this encounter:
Pt seen on urgent basis with symptoms of cough, elevated heart & respiration rate, sense of anxiety. Ate some chicken at lunch, shortly prior to onset of symptoms. Reports had an asthma exacerbation 2 weeks ago, reported to local ER, and was placed on a prednisone taper. States took last pill of Prednisone yesterday.
GENERAL: Anxious, alert, oriented, afebrile. O2 saturation 95 - 98% on room air.
SKIN: Good turgor. Normal skin tone. Dry. Diffuse erythema noted on chest & neck. Cheeks are flushed. Marked dermagraphism (tested @ lower back).
HEENT: Ears - TMs pearl, good COL. EACs clear. Eyes -sclerae white, conjunctivae mildly inflamed but appear moist. PERRLA-EOMI. Nostrils - patent. No inflammation. No rhinitis. Mouth - airway patent. Tonsils & uvula NL. Mucosa pink& moist. Neck - No lymphadenopathy or JVD. Airway midline. Thyroid NL. Supple.
CV: Mildly elevated systolic BP as noted. Mild tachycardia (resumed to 90 BPM after treatment of Albuterol & IM Diphenhydramine). Regular rhythm without murmur.
RESP: CTA in all fields (both prior to, and following Albuterol nebulizer tx.). Respirations initially rapid (22/min) and later at 18/min.
PSYCH: Patient initially anxious. Appeared calmer following treatments.
Assessment: Anaphylaxis due to substance (disorder) -995.0
Plan:
Administered in clinic immediately:
Diphenhydramine 50 mg IM single dose
Albuterol Nebulizer 0.5 mL treatment with NS
(Patient stated felt "much better" following these measures)
Recommended patient go home & rest. Take Prednisone as prescribed. Make appt. promptly with PCP. ER precautions for respiratory difficulty. Hydrate well with clear fluids.
Rx ? prednisone 20 mg oral tablet. Qty: 5. Take orally 1 daily for 5 days
The ICD-9 code of 995.0 is translated to ICD-10 code T78.2XXA, Anaphylactic shock. When I research this term, it is life-threatening and immediate ER attention needed. This is an office visit and pt was not sent to ER, so I am having difficulty assigning that code. Perhaps I'm not understanding, so I welcome any guidance on this.
Thanks in advance!
Pt seen on urgent basis with symptoms of cough, elevated heart & respiration rate, sense of anxiety. Ate some chicken at lunch, shortly prior to onset of symptoms. Reports had an asthma exacerbation 2 weeks ago, reported to local ER, and was placed on a prednisone taper. States took last pill of Prednisone yesterday.
GENERAL: Anxious, alert, oriented, afebrile. O2 saturation 95 - 98% on room air.
SKIN: Good turgor. Normal skin tone. Dry. Diffuse erythema noted on chest & neck. Cheeks are flushed. Marked dermagraphism (tested @ lower back).
HEENT: Ears - TMs pearl, good COL. EACs clear. Eyes -sclerae white, conjunctivae mildly inflamed but appear moist. PERRLA-EOMI. Nostrils - patent. No inflammation. No rhinitis. Mouth - airway patent. Tonsils & uvula NL. Mucosa pink& moist. Neck - No lymphadenopathy or JVD. Airway midline. Thyroid NL. Supple.
CV: Mildly elevated systolic BP as noted. Mild tachycardia (resumed to 90 BPM after treatment of Albuterol & IM Diphenhydramine). Regular rhythm without murmur.
RESP: CTA in all fields (both prior to, and following Albuterol nebulizer tx.). Respirations initially rapid (22/min) and later at 18/min.
PSYCH: Patient initially anxious. Appeared calmer following treatments.
Assessment: Anaphylaxis due to substance (disorder) -995.0
Plan:
Administered in clinic immediately:
Diphenhydramine 50 mg IM single dose
Albuterol Nebulizer 0.5 mL treatment with NS
(Patient stated felt "much better" following these measures)
Recommended patient go home & rest. Take Prednisone as prescribed. Make appt. promptly with PCP. ER precautions for respiratory difficulty. Hydrate well with clear fluids.
Rx ? prednisone 20 mg oral tablet. Qty: 5. Take orally 1 daily for 5 days
The ICD-9 code of 995.0 is translated to ICD-10 code T78.2XXA, Anaphylactic shock. When I research this term, it is life-threatening and immediate ER attention needed. This is an office visit and pt was not sent to ER, so I am having difficulty assigning that code. Perhaps I'm not understanding, so I welcome any guidance on this.
Thanks in advance!