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using the 1995 guidelines.

  1. #1
    Default using the 1995 guidelines.
    Medical Coding Books
    what level do you get out of this.
    1995 guidlines only.'

    This is a 70 y/o gentleman who has a H/O Atrial Fibrillation, Osteoarthritis,

    HTN and Atherosclerosis.

    CC: Chest Pain

    HPI: Patient describes sharp pleuritic pain on the left side of the chest when climbing stairs and with
    other activity. Pain started suddenly two days ago. Pain is generally continuous, but waxes and wanes
    with significant increase in pain upon inspiration. Pain is non-radiating. It is associated with mild
    diaphoresis and SOB. He has had a recent cough with periodic chills. Patient obtains best relief by
    sitting quietly.

    Medications include:
    Digoxin 0.25 mg., po, OD
    ASA 81 mg., po, OD
    Atenolol 50 mg., po, BID
    Motrin 200 mg., po, TID
    Lasix 40 mg., po, OD

    Constitutuional: 4 lb. wt. loss; chills, as noted, with some night sweats
    HEENT: No headaches, vision changes, nasal stuffiness or throat pain
    CV: History of intermittent Atrial Fibrillation; no valvular disorder
    Resp.: Recent cough, as noted: no H/O asthma or emphysema
    GI: No dyspepsia, dysphagia; nausea at times; no vomiting; no
    changes in bowel habits
    GU: No incontinence, dysuria, nocturia; no change in urination
    MS: Note generalized muscle weakness;(+) for knee pain with stairs;
    no gout attacks; no recent leg trauma
    Allergies: None
    Neuro: No changes in mentation; neg. for focal pain, parasthesias or
    extremity weakness
    Skin: Notes warm, erythematous patch in right calf

    Constitutional: 150/90, Temp. 100, P. 110, Wt. 198 lbs.
    HEENT: Conjunctiva clear, PERLA; tympanic membranes intact; fair
    dental repair
    Resp.: Fine rhonchi in lower left lobe, slight expiratory wheeze in the left
    lower lobe; neg. for the use of accessory muscles; chest neg. for
    deformity; palpation revealed mild left sided chest tenderness
    CV: PMI is slightly displaced 2 fingerbreadths to the left of the midclavicular
    line; S1 and S2 normal, intensity but irregular with a rate of
    approximately 100; questionable S3 gallop present; moderately loud
    apical systolic murmur; pedal pulses (+), femoral pulses are full; ankles
    show 1 (+) edema
    GI: B/S (+) in all 4 quadrants, no tenderness or mass palpated; liver and
    spleen palpation normal; rectal area neg.; findings- stool sample neg. for
    MS: No clubbing of fingers, normal ROM in all extremities; no tenderness or
    mass in joints; muscle strength 5/5; Homan's sign (+) rt. calf
    Neuro: Alert, apprehensive; sensory –normal pinprick sensation; normal motor
    exam; DTR's 2 (+); gait steady
    GU: Prostate normal size; no penile discharge; no tenderness in scrotal area
    Skin: No diaphoresis: warmth in rt. calf with tenderness
    Psych: Appears appropriately anxious; answers questions coherently

    EKG done today shows Atrial Fibrillation with ventricular response of 118. Diffuse ST-T changes nonspecic;
    however, ST-T changes are more pronounced than prior tracing. A.Fib. has reoccurred after
    stabilization for the prior 18 months. Pulse oximetry today show O2 saturation of 90%.
    Echocardiography shows Left Ventricular Ejection Fraction of 45%. Some depression of right
    ventricular function noted. There is a marked Tricuspid regurgitation with estimated pulmonary artery
    pressure of 50 mm of mercury.
    Probable acute pulmonary embolus, possible pneumonia, possible acute coronary syndrome.

    Nasal O2 @2L/min. continuous
    Dilaudid 2 mg., IM for chest pain stat
    ASA 81 mg., sublingual stat
    Admit to hospital

  2. #2
    Greeley, Colorado
    Who is reporting the admit?

  3. #3
    Is this an initial hosp visit? If so, I would code a 99221. It is lacking the PFSH, I only see Past Medical History, no social and no family.

  4. Default
    I agree. No social or family history.

    Quote Originally Posted by smillar View Post
    Is this an initial hosp visit? If so, I would code a 99221. It is lacking the PFSH, I only see Past Medical History, no social and no family.

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