Chapter 19: CPT Evaluation & Management Section Workbook Case 6 Answers and Rationale.

Hospital Progress Note

Subjective: Patient is without complaint. She states she feels much better. |1| No vomiting or diarrhea. She did have bowel movement yesterday. |2| No shortness of breath, no chest pain. |3|

The patient and daughter were questioned again about her cardiac history. She denies any cardiac history. She has no orthopnea, no dyspnea on exertion, no angina in the past and she has never had any heart problems in the past. |4|

Case discussed yesterday with Dr. Williams and I am waiting to find out on her surgery date.

Objective:
Vital signs: Shows a T-max of 99.6, T-current 98, pulse 72, respirations 18. Blood pressure 154/65, 02 sat 96% on room air. Accuchecks, 113, 132, 96, 98. |5|
General: No apparent distress, oriented x 3, pleasant Spanish-speaking female. |5|
Head, Ears, Eyes, Nose, Throat: Normocephalic, atraumatic. |6| Oropharynx pink and moist. |7| Left eye has sclera erythema. Pupils equal, round, and reactive to light accommodation (PERRLA). |8|
Laboratory Data: Shows C Diff toxin negative. Sodium 129, potassium 3.4, chloride 96, CO2 27, glucose 72, BUN 12, creatinine 0.6. Urine culture positive for E. coli, sensitive to Levaquin. |9|

Assessment:
1. Cholelithiasis
2. Cystitis
3. Conjunctivitis
4. Hyponatremia
5. Hypokalemia
6. Diabetes mellitus type 2
7. Hypertension

If the patient is not to go to surgery today, will feed the patient and likely discharge her if she tolerates regular diet. Will add Norvasc 5 mg p.o. daily. Also pleural effusion, small. Will repeat a chest X-ray PA and lateral this morning to evaluate that.

|1| HPI: Quality
|2| ROS: GI
|3| ROS: Respiratory
|4| ROS: Cardiovascular
|5| Exam: Constitutional
|6| Exam: Head, including face
|7| Exam: ENMT
|8| Exam: Eyes
|9| Lab tests reviewed

What are the CPT® and ICD-10-CM code(s) reported?
CPT® code: 99232
ICD-10-CM codes: K80.20, N30.90, H10.9, E87.1, E87.6, E11.9, I10

Rationale:
CPT® code: Subcategory: Subsequent Hospital Care (2 of 3 components), coded using 1995 guidelines
History — Expanded problem focused (HPI—Brief, ROS—Extended, PFSH—none)
Exam — Expanded problem focused (3 organ systems—limited exams of all three)
MDM — Moderate Complexity (Extensive diagnosis, Review labs, Moderate Risk [Two or more stable chronic illnesses]).

ICD-10-CM codes:
1. Cholelithiasis—In the ICD-10-CM Alphabetic Index, look for Cholelithiasis – see Calculus, gallbladder; Calculus, calculi, calculous/gallbladder referring you to K80.20.
2. Cystitis—Look in the Alphabetic Index for Cystitis. There are no other descriptors, use N30.90. Physician needs to document the infectious agent to report it.
3. Conjunctivitis—Look in the Alphabetic Index for Conjunctivitis NOS referring you to H10.9.
4. Hyponatremia—Look in the Alphabetic Index for Hyponatremia referring you to E87.1.
5. Hypokalemia—Look in the Alphabetic Index for Hypokalemia referring you to E87.6.
6. Diabetes mellitus type 2—Look in the Alphabetic Index for Diabetes, diabetic/type 2 referring you to E11.9.
7. Hypertension— Look in the Alphabetic Index for Hypertension referring you to I10.

Verify code selections in the Tabular List.