1 answer

What is the professional code and ICD-10-CM codes for this case? The patient is a 50-year-old...

Question:

What is the professional code and ICD-10-CM codes for this case? The patient is a 50-year-old white female with history of sudden desaturations in her pulse oximetry recently who had emergency CT scan of the chest done with no signs of pulmonary embolism. She just had bilateral atelectasis that is kind of bordering on pneumonic infiltrate. The patient was not getting up and is not using her incentive spirometry as she should. Even her mother said she should be getting up more and she is inclined to get her up more today even. The patient's incentive spirometry has been haphazardly done according to the nursing staff and she really needs to do this regularly every hour and this was told to the family. PHYSICAL EXAMINATION: VITAL SIGNS: The patient's blood pressure 155/81, pulse 98, respirations 18, temperature 37.1. Input 2835 and output 1475. LUNGS: Clear to auscultation. No E-to-A changes. No dullness to percussion. Normal respiratory effort. Normal chest wall expansion. HEART: S1 and S2 could be heard without murmur, gallop or rub. ABDOMEN: Soft, positive bowel sounds, no pain or masses, no hepatosplenomegaly, no abdominal bruits. EXTREMITIES: Showed no clubbing, cyanosis or edema. Cultures are negative so far of her sputum, but we are waiting on the final on that. IMPRESSION: 1. Obstructive sleep apnea syndrome. 2. Chronic obstructive pulmonary disease. 3. Atelectasis bordering on pneumonic infiltrate. 4. Restrictive defect. 5. History of seizures. PLAN: 1. Continue Xopenex q.4h. 2. Incentive spirometry 5 times per hour. 3. Await sputum Gram stain and C and S. 4. Wean oxygen and get her off oxygen, so she can go home off oxygen. 5. CPAP at 8 cm. I have strongly informed her that she needs to be get up and get moving and she needs to use her incentive spirometry. The patient has been placed on Levaquin p.o. 1 tablet daily and I think she should be on this for 14 days total and continue to dealing with her and hopefully she will improve over time. She probably needs to get another chest x-ray in 2 weeks also and to make sure her lungs have improved. I will see her in the morning.


Answers

Professional code is defined as necessary component to any proffesion needs to maintain standards for the individuals within that proffesion to adhere it brings about responsibility accountability and trust to the individual that the proffesion serves.

Obstructive sleep apnea G47. 33 is a specific icd 10 CM code that can be used to indicate a diagnosis of reimbursement purposes.

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