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Coding challenge :)

  1. #1
    Cool Coding challenge :)
    Medical Coding Books
    I know how I code it, but I wanted to bouce it off all of you and see if I'm in the majority.

    Pt has DMII and COPD and has a "daily" standing order to come in and have temp, pulse, resp rate, BP, blood glucose, pulse ox monitored and then receive Xopenex 1.25mg followed by Atrovent .5mg and then have pulse ox and occasionally resp rate re-checked and then is D/C home.

    The chart note from the RN states "last home tx 0730, states he is starting to feel "plugged up" "stuff coming up".
    Resp rate
    Pulse ox
    Glucose - 3*PP
    Notes 4 allergies
    Xopenex 1.25mg started via neb 1040
    Atrovent 0.5mg started via neb 1054
    Resp rate after tx 30
    02 sat 91% RA
    states "he can breath"
    signed off by RN

    How would you code this?

    E/M? Procedure codes? Drugs? Diagnoses?

    Thanks in advance for the insight!!
    Heidi Thompson, CPC

  2. Default
    I'd code only the neb and drugs. No e/m. w/ COPD

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