Chapter 19: CPT Evaluation & Management Section Workbook Case 9 Answers and Rationale.

Hospital Admission ^|1|

Chief Complaint: Nausea and vomiting, weakness ^|2|

HPI: The patient is a 78-year-old Hispanic female with a history of diabetes, hypertension, and osteoporosis who was just discharged after hospitalization for gastroenteritis three days ago. ^|3| She went home and was feeling fine, was tolerating regular diet ^|4| until yesterday when she vomited. ^|5| She stated she feels nauseated now, feels like she needs to throw up but cannot vomit. ^|6| Her last bowel movement was yesterday. She stated it was diarrhea ^|7| and states she has extreme ^|8| weakness. ^|9| No melena or hematochezia. ^|10| No shortness of breath, no chest pain. ^|11|

Medical History: Diabetes mellitus type 2. Hypertension. Osteoporosis. ^|12|

Surgical History: None. ^|12|

Medicines: Benadryl 25 mg daily, Diovan 320/25 one daily, calcium 600 daily, vitamin C 500 daily, multivitamin 1 tablet daily, Coreg CR 20 mg daily, Lipitor 20 mg at bedtime, metformin 1000 mg/day. ^|12|

Allergies: Morphine. ^|12|

Social History: No tobacco, alcohol or drugs. She is a widow. She lives in Marta. She is retired. ^|13|

Family History: Mother deceased after childbirth. Father deceased from asphyxia. ^|14|

ROS: Negative for fever, weight gain, weight loss. Positive for fatigue and malaise. ^|15|
Ears, Nose, Throat: Negative for rhinorrhea. Negative for congestion. ^|16|
Eyes: Negative for vision changes. ^|17|
Pulmonary: Negative for dyspnea. ^|18|
Cardiovascular: Negative for angina. ^|19|
Gastrointestinal: Positive for diarrhea, positive for constipation, intermittent changes between the two. Negative for melena or hematochezia. ^|20|
Neurologic: Negative for headaches. Negative for seizures. ^|21|
Psychiatric: Negative for anxiety. Negative for depression. ^|22|
Integumentary: Positive for rash for which she takes Benadryl. ^|23|
Genitourinary: Negative for dysfunctional bleeding. Negative for dysuria. ^|24|

Objective:
Vital Signs: Show a temperature max of 98.1, T-current 97.6, pulse 62, respirations 20, blood pressure 168/65. O2 sat 95% on room air. Accu-Chek, 135. ^|25|
Generally: No apparent distress, alert and oriented x 3, pleasant Spanish speaking female. ^|25|
Head, Ears, Eyes, Nose, Throat: Normocephalic, atraumatic. ^|26| Oropharynx is pink and moist. ^|27| No scleral icterus. ^|28|
Neck: Supple, full range of motion. ^|29|
Lungs: Clear to auscultation bilaterally. ^|30|
Cardiovascular: Regular rate and rhythm. No murmurs, gallops, rubs. ^|31|
Abdomen: Soft, nontender, nondistended. Normal bowel sounds. No hepatosplenomegaly. Negative Murphy’s sign. ^|32|
Back: Costovertebral angle tenderness. ^|33|
Extremities: No clubbing, cyanosis or edema. ^|34|

Laboratory Studies
Shows a sodium 125, potassium 3.1, chloride 90, CO2 27, glucose 103, BUN 13, creatinine 0.7, white count 8.3, hemoglobin and hematocrit 12.6, 37.1, platelets 195, 000. Differential shows 76% neutrophils. Amylase 42, CK-MB 1.7, troponin 0.05, CPK 59. PTT 26.9. PT and INR 12.9 and 1.09. UA shows 500 leukocyte esterase, negative nitrite, 15 of ketones, 10 to 25 WBCs. ^|35|

Gallbladder sonogram shows a 1.24 x 1 cm echogenic focus in the gallbladder, possibly representing gallbladder polyp or gallbladder mass. CT abdomen and pelvis shows cholelithiasis, small left pleural effusion, small indeterminate nodules both lung masses, no acute bowel abnormality and sclerotic appearance of right greater trochanter, no free air. ^|36|

Assessment
1. Nausea, vomiting, diarrhea, likely gastroenteritis
2. Cystitis
3. Hypokalemia
4. Hyponatremia
5. Cholelithiasis
5. Diabetes mellitus type 2
6. Hypertension

Plan: Will admit patient for IV hydration, add Levaquin 500 mg IV q 24 hours. Will add 20 mg KCl per L to IV fluid. ^|37| Get a general surgery consult for cholelithiasis. Will check studies, fecal white blood cells, C. diff toxin and fecal stool culture and sensitivity. ^|38|

|1| Choose from Initial Hospital Care Subcategory.
|2| Chief complaint.
|3| HPI: Timing.
|4| HPI: Quality.
|5| HPI: Timing.
|6| HPI: Severity.
|7| ROS: GI.
|8| HPI: Severity.
|9| HPI: Associated Sign & Symptom.
|10| ROS: GI.
|11| ROS: Respiratory.
|12| PFSH: Personal History.
|13| PFSH: Social History.
|14| PFSH: Family History.
|15| ROS: Constitutional.
|16| ROS: ENT.
|17| ROS: Eyes.
|18| ROS: Respiratory.
|19| ROS: Cardiovascular.
|20| ROS: GI.
|21| ROS: Neurologic.
|22| ROS: Psychiatric.
|23| Integumentary.
|24| ROS: GU.
|25| Exam: Constitutional.
|26| Exam: Head, including face.
|27| Exam: Mouth (ENMT).
|28| Exam: Eye.
|29 Exam: Neck.
|30| Exam: Respiratory.
|31| Exam: Cardiovascular.
|32| Exam: Gastrointestinal.
|33| Exam: GU (CVA tenderness is check for signs of kidney infection).
|34| Exam: Cardiovascular.
|35| Labs reviewed.
|36| Ultrasound and CT reviewed.
|37| IV Hydration with additives.
|38| Ordered additional lab.

What are the CPT® and ICD-10-CM code(s) reported?
CPT® code: 99222
ICD-10-CM codes: R11.2, R19.7, N30.90, E87.6, E87.1, K80.20, E11.9, Z79.84, I10

Rationale:
CPT® code: Subcategory—Initial Hospital Care (3 of 3 key components), coded using 1995 guidelines
History — Comprehensive (HPI—Extended, ROS—Complete, PFSH—Complete)
Exam — Comprehensive (8 organ systems)
MDM — Moderate Complexity (Extensive diagnoses, Limited data [reviewed radiology & labs, ordered labs], Risk—Moderate [IV hydration with additives]).

ICD-10-CM codes:
1. Nausea, vomiting, diarrhea, likely gastroenteritis (gastroenteritis is only a possible diagnosis, nausea, vomiting and diarrhea are symptoms, but the cause is undetermined, so they are coded). Look in the ICD-10-CM Alphabetic Index for Nausea/with vomiting referring you to R11.2 and Diarrhea, diarrheal referring you to R19.7.

2. Cystitis—Look in the Alphabetic Index for Cystitis with other descriptors referring you to N30.90.

3. Hypokalemia—Look in the Alphabetic Index for Hypokalemia referring you to E87.6.

4. Hyponatremia—Look in the Alphabetic Index for Hyponatremia referring you to E87.1.

5. Cholelithiasis—Look in the Alphabetic Index for Cholelithiasis – see Calculus, gallbladder. Look for Calculus, calculi, calculous/gallbladder referring you to K80.20.

6. Diabetes mellitus type 2—Look in the Alphabetic Index for Diabetes, diabetic/type 2 referring you to E11.9.

7. The patient is on long-term metformin to control her blood sugar. Look in the Alphabetic Index for Long-term (current) (prophylactic) drug therapy (use of)/oral/hypoglycemia referring you to Z79.84.

8. Hypertension— Look in the Alphabetic Index for Hypertension referring you to I10.

Verify code selections in the Tabular List.