A 37-year-old with a history of dyslipidemia and chronic pain. (Although dyslipidemia and chronic pain are listed as a history,
there is no documentation to support the conditions were treated at this encounter or that they affected the management of the current conditions. These conditions are not coded and are not taken into consideration for the level of medical decision making.) The patient is here for follow-up of bilateral lower extremity swelling. The patient tells me that the swelling responded to hydrochlorothiazide. EXAM: Very pleasant, no acute distress (NAD).
VITALS: P: 67, R: 18, Temp 98.6,
BP: 130/85.
ASSESSMENT:
Pulmonary hypertension: Etiology is not clear at this time, will do a work up and possible referral to a pulmonologist.
PLAN: I think we will need to evaluate the etiology of the pulmonary hypertension. The patient will be scheduled for a sleep study.
Required:
What are the CPT® and ICD-10-CM codes reported?
ICD-10-CM diagnosis codes provide the reason for seeking health care; ICD-10-PCS procedure codes tell what inpatient treatment and services the patient got; CPT (HCPCS Level I) codes describe outpatient services and procedures; and providers generally use HCPCS (Level II) codes for equipment, drugs, and supplies for the diagnosis
