Emergency Department (ED) sample medical coding chart 1
Chief Complaint & History of Present Illness :
19 year old male presents for headache.Patient states his symptoms started approximately six days ago with a left sided headache.He describes his pain as a throbbing sensation on the left side of his head and rates the pain as a 4/10.His symptoms got progressively worse and he developed visual disturbances.He had one episode of emesis today.Patient denies fever and ear pain.He notes that he was taking Aspirin and Advil for his symptoms.Patient denies history of migraines and any recent head injuries. Patient’s father had an ischemic stroke.
Medical Decision Making (MDM) :
19 year old man here with gradual onset migrainous headache.No trauma; no fever or neck stiffness, very unlikely for meningitis and reassuring neuro exam and gradual onset make SAH or mass unlikely.Feeling better here.Plan home migraine meds, clear return precautions, followup in clinic.
ED Diagnosis (Current Problem List) :
Problem Associated ICD-10-CM Code Status Onset
Migraine None Associated Active
Past Medical History :
PMH: None
Primary MD: MCC
Surgeries / Procedures: No recent surgery.
Allergies
No Known Drug Allergies
Home Medications
Aspirin-Acetaminophen-Caffeine 250 mg-250 mg-65 mg, 2 tablet orally every 6 hours PRN pain
Ondansetron, 4 milligram orally 4 times per day PRN nausea and vomiting(Duration: 5 days)
Prozac Oral, daily
wellbutrin, daily
Social History
Patient denies tobacco use and alcohol consumption.
Tobacco Use
Review Of Systems
ROS:
IX1 All systems reviewed and found to be negative except those mentioned in the history of present illness.
Vital Signs
Most Recent Set of Vitals:
BP: 128/77 08/29 22:44
Pulse: 90 08/29 22:44
Temp: 37.4 C 08/29 22:44
Resp: 18 08/29 22:44
02 Sat: 100% 08/29 22:44
Calculated BMI: 21.6 08/29 22:44
Additional Vitals:
Triage:
Temp 37.4 C 08/29 22:44
BP 1 128/77 08/29 22:44
Pulse 90 08/29 22:44
Resp 18 08/29 22:44
02 Sat%,PulseOx 100% 08/29/ 22:44
Vitals: Pulse Ox
02 Source : Room Air 02 Delivery : 02 L/min Fi02 %
Pulse Ox Reading: 100 % Interpretation: Normal Date/Time:
Physical Exam
GENERAL
Vital signs reviewed.
Gen/Psych: Cooperative
Head: Atraumatic, normocephalic
Eyes: Pupils equal, round, and reactive.Eyes nonicteric, noninjected
ENT: Mucous membranes moist, no exudate
Neck: Supple
CV: Regular rate and rhythm, no murmurs
Resp: Clear to auscultation bilaterally.No wheezes, rales or rhonchi
Abd: Soft, nontender
Neuro: Moves all extremities equally, good motor and sensation intact throughout, CN 2-12 grossly intact, gait stable
Skin: No lesions.No rashes.
Medical Decision Making (MDM) :
19 year old man here with gradual onset migrainous headache.No trauma; no fever or neck stiffness, very unlikely for meningitis
and reassuring neuro exam and gradual onset make SAH or mass unlikely.Feeling better here.Plan home migraine meds, clear
return precautions, followup in clinic.
ED Diagnosis (Current Problem List) :
Problem Associated ICD-10-CM Code Status Onset
Migraine None Associated Active
CPT code : 99282
Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making
G43909 Migraine, unspecified, not intractable, without status migrainosus
Emergency Department (ED) sample medical coding chart 2
Chief Complaint & History of Present Illness :
19 year old female presents to the ED with her mother for drainage of cyst on her right upper gluteal fold.The patient was sent in by Dr..The patient states the cyst has been draining all day.She has not applied any compresses for relief.
She denies allergies.LMP was 3 weeks ago.
Medical Decision Making (MDM) :
19 Year old female presents to ED with pilonidal cyst /abscess.Patient has been having pain to the sacral region for last few days.Otherwise healthy with no past medical history.On exam, there is active drainage noted from the pilonidal abscess.
Copious pus was drained.There is surrounding cellulitis.Plan to start antibiotics Keflex and Bactrim.Patient is advised to follow up with her PMD next 2 days wound check.Strict return precautions are given.She is in no acute distress and is discharged with
her mother.
ED Diagnosis (Current Problem List)
Problem Associated ICD-10-CM Code Status Onset
Pilonidal cyst with abscess L05.01 – PILONIDAL CYST WITH ABSCESS Active
Past Medical History :
PMH: Denies
Allergies
No Known Allergies
Home Medications
cephALEXin, 500 milligram orally 4 times per day (Duration: 7 days)
Sulfamethoxazole-Trimethoprim 800 mg-160 mg (DS), 1 tablet orally every 12 hours
Social History
Denies alcohol, illicit drug and tobacco use.Mother at bedside.
Review Of Systems
ROS:
IX1 All systems reviewed and found to be negative except those mentioned in the history of present illness.
Vital Signs
Most Recent Set of Vitals:
BP: 127/79 09/16 21:03
Pulse: 86 09/16 21:03
Temp: 36.8 C 09/16 18:28
Resp: 16 09/16 21:03
02 Sat: 98%(01/m)(Room Air) 09/16 21:03
Calculated BMI: 22.4 09/16 18:28
Additional Vitals:
Triage:
Temp 36.8 C 09/16 18:28
BP 1 139/100 Arm,Upper Lt Sitting NIBP 09/16 18:28
Pulse 115 09/16 18:28
Resp 20 09/16 18:28
02 Sat%,PulseOx 99% Room Air 09/16 18:28
Vitals: Pulse Ox [This section may be copied as needed]
02 Source : Room Air 02 Delivery : 02 L/min FiO2 %
Pulse Ox Reading: 99 % Interpretation: normal Date/Time:
Physical Exam
GENERAL
GENERAL: Awake, alert, oriented x3, no acute distress, well appearing
EYES: PERRL, EOMI
HENT: Trachea midline, nontender, no crepitus, no cervical lymphadenopathy, no meningismus
CVS: 51 S2, regular rate and rhythm, no obvious murmurs
PULMONARY: Bilateral clear lungs, no respiratory distress
ABDOMEN: Soft, nontender, no distension, no guarding or rebound, normal bowel sounds
EXTREMITIES: No swelling, nontender, no deformity
VASCULAR: Pulses equal and intact
SKIN: Cyst right upper gluteal fold, actively draining.
NEURO: A&Ox4, no acute neurological deficits, cranial nerves intact
PSYCH: No suicidal ideation or homicidal ideation, no acute hallucinations
Medical Decision Making (MDM) :
19 Year old female presents to ED with pilonidal cyst/abscess.Patient has been having pain to the sacral region for last few days.
Otherwise healthy with no past medical history.On exam, there is active drainage noted from the pilonidal abscess.Copious pus
was drained.There is surrounding cellulitis.Plan to start antibiotics Keflex and Bactrim.Patient is advised to follow up with her
PMD next 2 days wound check Strict return precautions are given.She is in no acute distress and is discharged with her mother.
ED Diagnosis (Current Problem List) :
Problem Associated ICD-10-CM Code Status Onset
Pilonidal cyst with abscess L05.01 – PILONIDAL CYST WITH ABSCESS Active
CPT code : 99282
Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making
L0501 Pilonidal cyst with abscess
Emergency Department (ED) sample medical coding chart 3
Chief Complaint & History of Present Illness :
19 year old female presents with urine incontinence onset 09/18/.She denies any hx of surgery.
Medical Decision Making (MDM) :
This is an otherwise healthy 19-year-old young woman who presents with a day of dysuria, frequency and incontinence.No fever. No flank pain.
Exam is normal.Abdomen is benign.No CVAT.No fever.
Urinalysis is consistent with UTI with 71 WBC, 37 RBC, 2+ leukocyte esterase, negative nitrites.This was sent for culture.
Pregnancy is negative.
Patient is being discharged home with a prescription for Macrobid for her uncomplicated cystitis.She will follow up with the Community Clinic later in the week and agrees to return here if worse.
ED Diagnosis (Current Problem List) :
Problem Associated ICD-10-CM Code Status Onset
UTI None Associated Active
Past Medical History :
PMH: none reported
Primary MD: MCC
Allergies
No Known Drug Allergies
Home Medications
Nitrofurantoin (12 hr Macrocrystal form), 100 milligram orally every 12 hours (Duration: 5 days)
Social History
nonsmoker, denies alcohol consumption
Tobacco Use
None Reported : TOBACCO HISTORY
Review Of Systems
ROS:
IX] All systems reviewed and found to be negative except those mentioned in the history of present illness.
Vital Signs
Most Recent Set of Vitals:
BP: 108/67 09/18/ 02:17
Pulse: 64 09/17/ 23:58
Temp: 36.8 C 09/18/ 02:19
Resp: 16 09/18/ 02:17
02 Sat: 99%(Room Air) 09/18/ 02:17
Calculated BMI: 20.2 09/17/ 21:51
Additional Vitals:
TRIAGE:
Temp 36.8 C 09/17/ 21:51
BP 1 113/69 09/17/ 21:51
Pulse 69 09/17/ 21:51
Resp 18 09/17/ 21:51
02 Sat%,PulseOx 100% Room Air 09/17/ 21:51
Vitals: Pulse Ox [This section may be copied as needed]
02 Source : Room Air 02 Delivery : 02 L/min Fi02 %
Pulse Ox Reading: 100 % Interpretation: Normal Date/Time:
Physical Exam
GENERAL
GENERAL: well-appearing, no apparent distress
HEAD: normocephalic, no signs of trauma
HEENT: eyes PERRL, conjunctiva normal, posterior oropharynx normal, mucous membranes moist
NECK: supple, no meningeal signs, no JVD
CHEST: nontender, lungs clear
HEART: regular rate and rhythm
ABDOMEN: soft, nontender, nondistended, no peritoneal signs
BACK: no midline tenderness, no CVAT
EXTREMITIES: no cyanosis, no edema
NEURO: patient is awake and alert, no focal deficits
SKIN: warm and dry
PSYCH: calm, cooperative
Medical Decision Making (MDM) :
This is an otherwise healthy 19-year-old young woman who presents with a day of dysuria, frequency and incontinence.No fever. No flank pain.
Exam is normal.Abdomen is benign.No CVAT.No fever.
Urinalysis is consistent with UTI with 71 WBC, 37 RBC, 2+ leukocyte esterase, negative nitrites.This was sent for culture.
Pregnancy is negative.
Patient is being discharged home with a prescription for Macrobid for her uncomplicated cystitis.She will follow up with the
Community Clinic later in the week and agrees to return here if worse.
ED Diagnosis (Current Problem List) :
Problem Associated ICD-10-CM Code Status Onset
UTI None Associated Active
Disposition Decision Date/Time:
# D/C from ED to: Home
CPT code: 99283
Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making
N390 Urinary tract infection, site not specified