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Coding for Asthma patient

  1. #1
    Question Coding for Asthma patient
    Medical Coding Books
    Patient comes in with asthma attack - doctor bills e/m with meds; aerosol treatments; pulse ox - multiples - how would this be coded and with what modifiers - and do you see reimbursements on all these services?

  2. #2
    Location
    Columbia, MO
    Posts
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    this is a hard question answer with out the documentation, you could have prolonged time for the physician in addition to the E&M, If you have multiple treatments then you use the 76 modifier on those and a 25 on the visit level. most of the insurances will bundle the drugs into the nebs and the plus ox will bundle with most payers as well. With specific documentation my answer will be better.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default
    Here is an example chart documentation:
    Illness Care
    HPI Given By: mother
    Chief Complaint: wheezing
    History of Present Illness: Mom noted labored breathing last night; gave xopenex mdi tx. From 7am-8am today Mom gave 2 puffs x 4; last mdi tx was 1 hr ago. Cough since yest. No fever.
    Some nausea last night and this am. Denies vomiting and diarrhea.




    Past, Family, Social and Surgical History

    Past History: Reactive airways/wheezing treated with albuterol, flovent in past
    Hosp Sept 2005 for asthma
    Family History: No asthma
    Denies kidney dze.
    Social History: Lives with Mom; visits Dad 2 days a week.
    No smokers.
    1 cat indoor; 1 dog outside.
    Grandparents watch pt alot and they smoke and have 1 dog.





    Vital Signs
    Weight: 50 lbs /22.73 kg Change: -1 lbs /-450 g Previous: 51.0 lbs /23.18 kg on 03/17/2009
    BMI: 18.2 Change: -0.40 Previous: 18.6 on 03/17/2009
    Temperature: 97 F /36.1 C Temporal



    Additional Information
    Asthma Questionnaire given to family
    Initial Patient Intake By: April 1, 2009 10:04 AM

    Peak Flow, Oximetry
    Initial Pulse Oximetry: 92% Initial Pulse Rate: 131 b/min
    Initial Assessment By: , RN April 1, 2009 10:15 AM
    Oximetry After Rx #1: 96% Pulse Rate After Rx #1: 137 b/min
    Assessment After Rx #1 By: , RN April 1, 2009 10:27 AM
    Oximetry After Rx #2: 96% Pulse Rate After Rx #2: 133 b/min
    Assessment After Rx #2 By: , RN April 1, 2009 10:56 AM
    Oximetry Before Rx #3: 94% Pulse Rate Before Rx #3: 143 b/min
    Assessment Before Rx #3 By: , RN April 1, 2009 11:08 AM
    Oximetry After Rx #3: 96% Pulse Rate After Rx #3: 137 b/min
    Assessment After Rx #3 By: , RN April 1, 2009 11:52 AM


    Physical Exam
    General: alert; retracting, labored breathing; articulate.
    Skin: normal, no rashes or lesions
    L TM: normal
    R TM: normal
    Pharynx: normal
    Neck: supple, no masses, trachea midline, full ROM
    Lungs: Resp rate 60-70; supraclavicular and subcostal retractions; diminished bs throughout; faint hi pitched weeze over right posterior field
    Heart: normal S1 S2 without murmur
    S/P Xopenex 1.25mg neb #1) Resp rate 60; less intense supraclavicular and subcostal retractions; pulse ox 96%. Sightly improved aeration; now with hi pitched wheezes b/l and crackles over right posterior lung field. James J DePiore MD, April 1, 2009 10:37 AM Will give 30mg Orapred (ODT) now and repeat xopenex neb.
    S/P Xopenex 1.25mg neb #2) Resp rate 50-60; less intense supraclavicular and subcostal retractions; pulse ox 94%. Improved aeration; few hi pitched wheezes b/l and less intense crackles over right posterior lung field. James J DePiore MD, April 1, 2009 11:31 AM
    S/P Xopenex 1.25mg neb #3) Resp rate 44; No retractions. Faint intermittent wheeze over posterior fields and faint crackle over right posterior field. Pulse ox 96%. MD, April 1, 2009 12:02 PM



    Impression & Recommendations:

    Problem # 1: ASTHMA NOS W/ACUTE EXACERBATION (ICD-493.92)
    Improved aeration and decreased wob as noted above after 3rd xopenex tx. Will increase xopenex mdi to 4-6 puffs q 4-6 hrs and start Flovent 2 puffs bid until acut sx's resolve then cont qd thereafter. Orpared and zithromax as prescribed.
    Call for worsening or persistent sx's; sooner for increased wob or for fevers.
    Orders:
    Ofc Vst, Est Level IV (Detailed) (CPT-99214)
    Measurement of blood oxygen level, multiple (CPT-94761)
    Xopenex Inhalation 1.25 mg (J7612)
    Airway inhalation treatment (CPT-94640)
    Xopenex Inhalation 1.25 mg (J7612)
    Airway inhalation treatment (CPT-94640)
    Xopenex Inhalation 1.25 mg (J7612)
    Airway inhalation treatment (CPT-94640)


    Medications Added to Medication List This Visit:
    1) Orapred 15 Mg/5ml Soln (Prednisolone sodium phosphate) .... 2 teaspoon po each day for 4 days.
    2) Zithromax 200 Mg/5ml Susr (Azithromycin) .... 6 ml by mouth once day one and then 3ml by mouth once daily for the next four days.



    Prescriptions:
    ZITHROMAX 200 MG/5ML SUSR (AZITHROMYCIN) 6 ml by mouth once day one and then 3ml by mouth once daily for the next four days. #18ml x 0
    Entered and Authorized by: MD
    Signed by: MD on 04/01/2009
    Method used: Print then Give to Patient
    ORAPRED 15 MG/5ML SOLN (PREDNISOLONE SODIUM PHOSPHATE) 2 teaspoon po each day for 4 days. #QS x 0
    Entered and Authorized by: MD
    Signed by: MD on 04/01/2009
    Method used: Print then Give to Patient



    Patient Care Documentation
    1: Aerosol treatment with Xopenex 1.25mg complete. Given by, RN, April 1, 2009 10:14 AM
    2: Orapred ODT 2 tabs administered in office , RN, April 1, 2009 10:36 AM
    3: Aerosol treatment with Xopenex 1.25mg complete. Given by , RN, April 1, 2009 10:39 AM
    4: Aerosol treatment with Xpoenex 1.25mg complete. Given by , RN, April 1, 2009 11:43 AM

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