Forum - Questions & Answers

Apr 8th, 2011 - mjadea2010 1 

cpt4

LOCATION: In-patient Hospital
PATIENT: Donald Harris
ATTENDING PHYSICIAN: Timothy L. Pleasant, MD
The patient is doing relatively well in general. I believe the sodium of 152 that was done yesterday morning was wrong since it has dropped down to 132 in 6 hours, which is impossible to happen.
He continues to need oxygen and he continues to be hypoxic. His V/Q scan showed intermediate probability, but his ABGs were not suggestive of respiratory alkalosis.
PHYSICAL EXAMINATION: Blood pressure seems to be stable. Heart rate is 70 per minute, paced. He is afebrile. He has decreased air entry bilaterally in the bases. I did not hear any crackles. Abdomen is negative. Extremities show no edema.
Chest x-ray shows some bilateral pleural effusions, more on the right side.
Creatinine was 0.8. Basic metabolic panel was normal today with a sodium of 139.
IMPRESSION:
1. Severe congestive heart failure
2. Hypoxia probably related to the bilateral pleural effusions
3. Pleural effusion
PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the pulmonologist on call in the morning to check on him and see if we could do a therapeutic and diagnostic thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural effusions. I discussed this with the patient. He agrees with the plan.


What section of the CPT-4 manual will be used to code the attending physician’s services? ____________________



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Apr 11th, 2011 -

re: cpt4

99231-99233

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Jun 4th, 2011 -

re: cpt4

PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the pulmonologist on call in the morning to check on him and see if we could do a therapeutic and diagnostic thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural effusions. I discussed this with the patient. He agrees with the plan.

Identify the correct procedure (CPT-4) code(s) for the above scenario:

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Oct 26th, 2012 - Dede 3 

re: cpt4

[PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the pulmonologist on call in the morning to check on him and see if we could do a therapeutic and diagnostic thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural effusions. I discussed this with the patient. He agrees with the plan.

Identify the correct procedure (CPT-4) code(s) for the above scenario:
]

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Sep 14th, 2013 - ujonwest 4 

re: cpt4

[[PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the pulmonologist on call in the morning to check on him and see if we could do a therapeutic and diagnostic thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural effusions. I discussed this with the patient. He agrees with the plan.

Identify the correct procedure (CPT-4) code(s) for the above scenario:
]

]

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Sep 28th, 2013 - tamlynn 1 

re: cpt4

[[PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the pulmonologist on call in the morning to check on him and see if we could do a therapeutic and diagnostic thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural effusions. I discussed this with the patient. He agrees with the plan.

Identify the correct procedure (CPT-4) code(s) for the above scenario:
]

]

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Feb 10th, 2015 - WAlcorn423 2 

re: cpt4

[LOCATION: In-patient Hospital
PATIENT: Donald Harris
ATTENDING PHYSICIAN: Timothy L. Pleasant, MD
The patient is doing relatively well in general. I believe the sodium of 152 that was done yesterday morning was wrong since it has dropped down to 132 in 6 hours, which is impossible to happen.
He continues to need oxygen and he continues to be hypoxic. His V/Q scan showed intermediate probability, but his ABGs were not suggestive of respiratory alkalosis.
PHYSICAL EXAMINATION: Blood pressure seems to be stable. Heart rate is 70 per minute, paced. He is afebrile. He has decreased air entry bilaterally in the bases. I did not hear any crackles. Abdomen is negative. Extremities show no edema.
Chest x-ray shows some bilateral pleural effusions, more on the right side.
Creatinine was 0.8. Basic metabolic panel was normal today with a sodium of 139.
IMPRESSION:
1. Severe congestive heart failure
2. Hypoxia probably related to the bilateral pleural effusions
3. Pleural effusion
PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the pulmonologist on call in the morning to check on him and see if we could do a therapeutic and diagnostic thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural effusions. I discussed this with the patient. He agrees with the plan.


What section of the CPT-4 manual will be used to code the attending physician’s services? ____________________



]

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