Emergency Department (ED) sample medical coding chart 1
Chief complaint: Sore throat, cough
History of present illness: The patient is a 18 year old male presenting with sore throat and cough.Three weeks ago the sore throat started and has not improved.He also has a cough productive of colorless sputum.The cough started 2 weeks ago.
Denies fever, chills, night sweats, headaches, dizziness, chest pain, palpitations, shortness of breath, hemoptysis, nausea, vomiting, abdominal pain, numbness, tingling or weakness.
MDM: The patient is a 18 year old male who presented to the emergency department with a sore throat and cough.Airway is patent, tolerating oral secretions, tolerating p.o. Liquids, not tachycardic or febrile, oxygen saturation is adequate on room air, and no other physical exam/history findings to suggest acute airway or respiratory compromise.On examination the patient had exudative discharge and enlarged tonsils.Much of this discharge was removed with warm normal saline gargles in the ED.I was able to manually express a small amount of discharge and both tonsils which the patient tolerated without difficulty and told me he was feeling better after treatment.He had a negative streptococcal antigen test.Up to date on immunizations.
Clinically, there was no evidence for peritonsillar abscess, Ludwig’s angina, retropharyngeal abscess, epiglottitis or other serious throat disease.I was able to manually expressed a small amount of discharge from bilateral tonsils which patient tolerated without difficulty.Patient is comfortable with plan to treat with amoxicillin, OTC analgesics, and primary care follow-up.
Regarding the patient’s cough I think this is most likely due to postnasal drip.Chest x-ray was unremarkable for pneumonia, pulmonary edema, pleural effusion, pneumothorax, rib fracture.Abdominal examination was benign and I doubt mono or splenic rupture at this time.Counseled and educated patient on treatment plan and risks and benefits of treatment.Close
follow-up advised.Patient understands that we are not able to diagnose all conditions in the emergency department, and that although at this time there are no worrisome symptoms and patient appears to be stable, patient will need to return at once if any recurrent, worsening, or new symptoms.
Medical history: No diabetes, hypertension or peripheral artery disease.
SOCIAL: Denies alcohol, tobacco, or recreational drug use.
ROS: Constitutional: No fevers, chills, night sweats.
Head: No headaches, head injury.
Ears: No ear aches.No ear discharge, new auditory deficits.
Nose: No epistaxis, rhinorrhea, sinus congestion.
Throat: Positive sore throats.No trouble swallowing, muffled voice.
Cardiovascular: No chest pain, palpitations, chest wall injuries.
Respiratory: Positive coughs.Positive productive coughs.No shortness of breath.No hemoptysis.
Abdominal: No abdominal pain, nausea, vomiting.
Skin: No rashes.
PE: Vitals: Reviewed by me.
Constitutional: Well developed, well nourished.No acute distress.
Head: Atraumatic, normocephalic.
Eyes: Extraocular movements in tact.Pupils are 5mm, ERRLA.
Nose: Patent nares bilaterally.Nasal mucosae is pink, moist.
Mouth/Throat: Moist membranes.Uvula midline.Oropharynx is pink, moist.Bilaterally enlarged tonsils with exudate
discharge.Floor of the mouth is soft.
Neck: Supple.No JVD.
Cardiovascular: Normal heart rate and regular rhythm.CTA.
Respiratory: Non-labored breathing.No accessory muscle use.Lungs CTA.
Gastrointestinal: Soft, non-tender.Bowel sounds audible in all four quadrants and epigastrium.No masses or bruits.
Musculoskeletal: Full range of motion with passive and active testing.No obvious deformity.
Neurologic: Awake, alert, and oriented to time, place, and person.CNII-XII grossly in tact.Motor strength is 5/5.Sensation
intact to fine touch.Gait and coordination are grossly normal.
Peripheral Vascular: Radial pulses 2+ and equal bilaterally.Capillary refill less than 3 seconds.
Skin: Warm, dry.No erythema or lacerations.
ED Diagnosis (Current Problem List)
Problem Associated ICD-10-CM Code Status Onset
Cough R05 – COUGH Active
Past Medical History :
PMH: See above
Allergies
No Known Drug Allergies
Home Medications
Amoxicillin, 500 milligram orally 2 times per day (Duration: 7 days)
Tobacco Use
None Reported : TOBACCO HISTORY Last Documented By: SHERRY H. SHEEHAN, RN on 05/09/
Review Of Systems
ROS: See above
Vital Signs
Most Recent Set of Vitals:
BP: 118/61 09/01/ 10:10
Pulse: 81 09/01/ 10:10
Temp: 36.7 C 09/01/ 10:10
Resp: 16 09/01/ 10:10
02 Sat: 98%(Room Air) 09/01/ 10:10
Calculated BMI: 32.4 09/01/ 10:10
Vitals: Pulse Ox [This section may be copied as needed]
02 Source : Room Air 02 Delivery : 02 L/min FiO2 %
Pulse Ox Reading: 98 % Interpretation: Normal Date/Time:
Physical Exam
GENERAL
CXR [This section may be copied as needed]
CXR was: Interpreted by radiologist
Interpretation:
FINDINGS:
The cardiomediastinal silhouette is within normal limits for age.There is no
evidence of consolidation, pulmonary edema, pleural effusion, or pneumothorax.
No acute rib fractures visualized.
IMPRESSION:
1.No radiographic evidence of acute cardiopulmonary disease.
Problem Associated ICD-10-CM Code Status Onset
Cough R05 – COUGH Active
Disposition
Disposition Decision Date/Time:
D/C from ED to: Home
Condition at D/C: Improved
CPT code :
99283 -25 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
71046 Radiologic examination, chest; 2 views
Emergency Department (ED) sample medical coding chart 2
Chief Complaint & History of Present Illness :
18yo F with R index finger avulsion injury sustained 08/30/2019 when opening a connector door on a train.TDAP UTD.Patient
reports she performed basic wound care 08/30/2019.Moves without issue.Patient complains of mild pain.Patient
requesting further evaluation.
Medical Decision Making (MDM) :
18-year-old female with hx of mitochondrial disease, with superficial avulsion injury to the right 2nd digit sustained 08/30/2019 while
on a train.No repair necessary.Wound was irrigated by ER technician under my supervision and wound care provided.Advised
patient on continued wound care and signs of infection to be aware of, especially given immunocompromised state.Patient to
follow up with primary care in 3-5 days if wound not healing appropriately.ER return precautions reviewed.Patient and parents
verbalized understanding of plan.
ED Diagnosis (Current Problem List) :
Associated ICD-10-CM Code Status Onset
Avulsion of skin None Associated Active 2019
Past Medical History :
PMH: mitochondrial disease
Social History
freshman at UC Merced, parents at bedside
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: 126/85 08/31/ 12:38
Pulse: 78 08/31/ 12:38
Temp: 37.2 C 08/31/ 12:38
Resp: 16 08/31/ 12:38
02 Sat: 99%(Room Air) 08/31/ 12:38
Calculated BMI: 19.6 08/31/ 12:38
comment:
Physical Exam
GENERAL
General: Awake, alert, oriented x3, cooperative, and in no apparent distress.
Head: Normocephalic and atraumatic.
Eyes: Pupils equal and reactive to light, extraocular movements intact, sclera anicteric.
ENT: Airway patent and protected.
Neck: No meningeal signs
Respiratory: Clear to auscultation bilaterally, no respiratory distress.
Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops.
Musculoskeletal: Extremities atraumatic, ROM intact.Peripheral pulses intact throughout and symmetric.
Neurologic: Moves all extremities normally, speech and coordination normal.
Skin: 1 cm superficial avulsion injury to the palmar aspect of right 2nd digit.No erythema or purulent drainage.No
acute appearing lesions or rashes noted.
Medical Decision Making (MDM) :
18-year-old female with hx of mitochondrial disease, with superficial avulsion injury to the right 2nd digit sustained 08/30 while
on a train.No repair necessary.Wound was irrigated by ER technician under my supervision and wound care provided.Advised
patient on continued wound care and signs of infection to be aware of, especially given immunocompromised state.Patient to
follow up with primary care in 3-5 days if wound not healing appropriately.ER return precautions reviewed.Patient and parents
verbalized understanding of plan.
ED Diagnosis (Current Problem List) :
Problem Associated ICD-10-CM Code Status Onset
Avulsion of skin None Associated Active
Disposition
Disposition Decision Date/Time:
D/C from ED to: Home
Condition at D/C: stable
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
S61200A Unspecified open wound of right index finger without damage to nail, initial encounter
Emergency Department (ED) sample medical coding chart 3
Chief Complaint & History of Present Illness :
18 year old female presents with pregnancy issues at 9 weeks.Patient reports having stomach pain last night that felt like kicking, but she knew it was too early.She states that her stomach felt heavy, and she woke up with the same pain this morning along with vaginal spotting.Standing and walking aggravates her pain.Patient is G2P1.
Medical Decision Making (MDM) :
Medical decision making this is an 18-year-old female who is pregnant she had some minor pink spotting as well as lower abdominal discomfort.Ultrasound shows a 9 week intrauterine pregnancy with good heart beat.Patient is clinically well she is Rh positive no signs of infection.Plan patient is reassured.Plan of recheck at Community Clinic for prenatal care as scheduled.Vaginal rest.Recheck if increased pain or bleeding.Impression threatened AB.
ED Diagnosis (Current Problem List) :
Problem Associated ICD-10-CM Code Status Onset
Threatened miscarriage None Associated Active 2019
Past Medical History :
PMH: None
Primary MD: MCC
Historical Diagnoses (Full Problem List)
AP – Abdominal pain (2016), Ovarian cyst rupture (2016)
Allergies
Bupropion(hives)
Home Medications
Analpram-HC Cream, 1 application rectally 4 times per day PRN hemorrhoids
Colace, 250 milligram orally every day
Epsom Salt Solution, 1 application topically 3 times per day
Motrin, 600 milligram orally every 6 hours PRN pain
prenatal ukn type,
Tucks 50 % Medicated Pads, 1 pad topically every day PRN skin irritation
Immunizations
Tdap – 115 (2017)
Social History
Unremarkable
Tobacco Use
None Reported : TOBACCO HISTORY Last Documented By: AMANDA TARGETT, RN on 01/20/19:31
Alcohol Use
None Reported : ALCOHOL HISTORY Last Documented By: KRISTEN HOFFMAN, RN on 12/01/18:53
Recreational Drug Use
None Reported : RECREATIONAL DRUG HISTORY Last Documented By: IAN R. CANTOR, RN on 04/07/21:04
Review Of Systems
ROS: No fever or chills
No visual changes
No sore throat or earache
No chest pain or palpitations
No shortness of breath or cough
No pain with urination or hematuria
No abdominal pain nausea vomiting or diarrhea
No skin rashes
No focal weakness or numbness
No bruising or ecchymosis
ROS: Rest of the review of systems is negative except as listed in the HPI
Vital Signs
Most Recent Set of Vitals:
BP: 110/64 09/30/2019 11:29
Pulse: 94 09/30/2019 11:29
Temp: 36.7 C 09/30/2019 11:29
Resp: 16 09/30/2019 11:29
02 Sat: 99%(Room Air) 09/30/2019 11:29
Calculated BMI: 27.5 09/30/2019 11:29
Additional Vitals:
Triage:
Temp 36.7 C 09/30/2019 11:29
BP 1 110/64 Arm,Upper Lt Sitting 09/30/2019 11:29
Pulse 94 Monitor 09/30/2019 11:29
Resp 16 Regular 09/30/2019 11:29
02 Sat%,Pulse0x 99% Room Air 09/30/2019 11:29
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: Alert and oriented x3.Well developed, well nourished, well appearing.Anxious resting comfortably in bed.
Non icteric.
Hematologic: no bruising or ecchymosis.
Skin: Warm and dry, no rashes or lesions.
HENT: Normocephalic, atraumatic, pharynx moist and non injected.
Eyes: PERRL, EOMI, conjunctiva pink with no discharge.
Neck: Supple, no adenopathy.
Respiratory: Lungs clear, no rales, no rhonchi, no wheezing, no accessory muscle use.
Heart: Regular rate and rhythm, no murmurs.
Abdomen: Soft, nontender, active bowel sounds, nondistended, no guarding or rebound.
GU: no CVA tenderness.
Extremities: No edema, no calf tenderness.
Neuro: No focal weakness, no facial asymmetry, moves all extremities normally, normal speech pattern, normal gait.
Date / Time : Ultrasound of : PREG 1ST TRI SINGLE ENDOVAG
Ultrasound was : Interpreted by Radiologist
Interpretation :
FINDINGS:
Uterus: Again noted is a partial uterine duplication. Endometrium: Within the left horn there is an intrauterine gestation with fetal pole and yolk sac identified.Fetal heart rate is 205 BPM.Sub membranous collections compatible with sub chorionic hematoma are seen with 2 collections identified measuring 12 x 13 x 3 mm and 23 x 17 x 8 mm. Cervix is closed.
Ovaries: Right ovary is normal in size and appearance.Again noted is a left ovarian or paraovarian cyst currently measuring 22 x 14 x 12 mm
Free Fluid: None.
Crown-rump length corresponds to a sonographic age of 9 weeks and an EDD of 05/04/2020.LMP is 07/28/2019 corresponding to a clinical age of 9 weeks 1 day and EDD of 05/03/.
IMPRESSION:
1.Nine week living intrauterine gestation within left uterine horn of a partially duplicated uterus.
2.Two subchorionic hematomas are noted.
Medical Decision Making (MDM) :
Medical decision making this is an 18-year-old female who is pregnant she had some minor pink spotting as well as lower abdominal discomfort.Ultrasound shows a 9 week intrauterine pregnancy with good heart beat.Patient is clinically well she is Rh positive no signs of infection.Plan patient is reassured.Plan of recheck at Community Clinic for prenatal care as scheduled.
Vaginal rest.Recheck if increased pain or bleeding.Impression threatened AB.
ED Diagnosis (Current Problem List) :
Problem Associated ICD-10-CM Code Statu Onset
Threatened miscarriage None Associated Active
Disposition
Disposition Decision Date/Time:
D/C from ED to: Home
CPT code :
99284-25
Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making
76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester, transabdominal approach; single or first gestation
76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal