Question: Need To Know Any Applicable Cpt Codes, Modifier Codes, ICD-10-CM Codes And HCPCS Codes Based On The Patient Scenario.

FILE HOME INSERT DESIGN PAGE LAYOUT REFERENCES Cassandra – Hospital Emergency Word REVIEW VIEW DEVELOPER ADD-INS MAILINGS +++++++ Module 5: Emergency Medicine – Report 21: Emergency Department Services LOCATION: Hospital Emergency Department / PATIENT Blanche Denver / PHYSICIAN. Paul Sutton, MD SUBJECTIVE: A 91-year-old female who presents accompanied by her son sent in from the Nursing Home. This patient is a widow and had been living by herself until last summer. She has been taking hydrocodone 2 tablets daily for the past 4 years for chronic pain About 5 weeks ago, this medication was discontinued. The patient was started on Ativan after the hydrocodone was discontinued. However, she got sleepy from the dose she was taking and this was decreased. More recently, she has been only taking 0.25 mg daily and she is being weaned off of the medication all together The patient is brought in now because of shakes. This started a couple of hours ago today She has been very upset and anxious, and short of broath as well No chest pain and no cough. According to her son, these symptoms have been frequent the past several weeks and seem to be getting more frequent PAST MEDICAL HISTORY: 1. Hypertension 2. Hypothyroidism 3. Atrial fibrillation 4. She did have pulmonary embolism about 5 or 10 years ago after a hip fracture She remains on Coumadinat present 5. No history of congestive heart failure or asthma. SOCIAL HISTORY. No tobacco use No alcohol use She is a widow for 4 years REVIEW OF SYSTEMS. CONSTITUTIONAL No fever chills or sweats. CARDIOVASCULAR No chest pain or orthopnea RESPIRATORY somewhat short of breath, no cough OBJECTIVE This is an alert, but extremely anxious appearing 91-year-old fomalo. VITAL SIGNS Temperature is 365 degrees Pulse 64 Respirations 27 Blood pressure 126/94 Oxygen saturation 87%, but came up into the upper 90s with time and with oxygen HEENT. Conjunctive and lids normal Mouth Well hydrated. Pharynx normal NECK Supple without lymphadenopathy. Nothyromegaly. No jugular venous distension RESPIRATIONS Easy LUNGS Clear There were no roles. There was no wheezing She is moving air normally HEART Regular rate and thythm. No murmurs or extra heart sounds heard Chest wall without deformities and no localizing tenderness ABDOMEN Soft and nontender with normal bowel sounds, No hepatosplenomegaly. No pulsatile masa No ventral hernia. Noedema SKIN. No rash seen. No nodules felt ASSESSMENT: 1. Tremors. 2. Anxiety. 3. Hypothyroidism. PLAN. The patient looked extremely anxious and was given a small dose of Ativan 0.5 mg IV. This gave her good symptomatic relin EKG is done and show De acute changes. Chest x-ray is done and reviewed by me and shows no evidence of congestive heart failure or pneumonia Lab work includes TSH which is actually elevated at 8.5 and this would indicate hypothyroidism This should not be contributing to the patients present symptoms INR is slightly subtherapeutic at 16 The patient’s oxygen saturation stayed in the upper 90s even while off oxygen. She had good symptomatic relief from the Ativan I believe her symptoms are almost all anxiety related I am going to go ahead and increase her Ativan to 0.25 mg bid and asked that she be followed up with her primary physician this week Need the following codes if applicable: CPT Code, Modifier Code, ICD-10-CM Code, HCPCS Code +++++++ T7 WORD OR Type here to search