WHAT ARE THE ICD-10-CM AND CPT CODES??? Scenario 1 SUBJECTIVE: This 23-year-old white female presents with complaint of
Posted: Thu Mar 31, 2022 8:11 am
WHAT ARE THE ICD-10-CM AND CPT CODES???
Scenario 1
SUBJECTIVE: This 23-year-old white female
presents with complaint of allergies. She used to have allergies
when she lived in Seattle, but she thinks they are worse here. In
the past, she has tried Claritin, and Zyrtec. Both worked for short
time but then seemed to lose effectiveness. She has used Allegra
also. She used that last summer and she began using it again two
weeks ago. It does not appear to be working very well. She has used
over-the-counter sprays but no prescription nasal sprays. She does
have asthma but does not require daily medication for this and does
not think it is flaring up.
MEDICATIONS: Her only medication currently is
Ortho Tri-Cyclen and the Allegra.
ALLERGIES: She has no known medicine
allergies.
OBJECTIVE:
Vitals: Weight was 130 pounds and blood pressure 124/78.
HEENT: Her throat was mildly erythematous without exudate. Nasal
mucosa was erythematous and swollen. Only clear drainage was seen.
TMs were clear.
Neck: Supple without adenopathy.
Lungs: Clear.
ASSESSMENT: Allergic rhinitis.
PLAN:
1. She will try Zyrtec instead of Allegra again. Another option
will be to use loratadine. She does not think she has prescription
coverage so that might be cheaper.
2. Samples of Nasonex two sprays in each nostril given for three
weeks. A prescription was written as well.
Scenario 1
SUBJECTIVE: This 23-year-old white female
presents with complaint of allergies. She used to have allergies
when she lived in Seattle, but she thinks they are worse here. In
the past, she has tried Claritin, and Zyrtec. Both worked for short
time but then seemed to lose effectiveness. She has used Allegra
also. She used that last summer and she began using it again two
weeks ago. It does not appear to be working very well. She has used
over-the-counter sprays but no prescription nasal sprays. She does
have asthma but does not require daily medication for this and does
not think it is flaring up.
MEDICATIONS: Her only medication currently is
Ortho Tri-Cyclen and the Allegra.
ALLERGIES: She has no known medicine
allergies.
OBJECTIVE:
Vitals: Weight was 130 pounds and blood pressure 124/78.
HEENT: Her throat was mildly erythematous without exudate. Nasal
mucosa was erythematous and swollen. Only clear drainage was seen.
TMs were clear.
Neck: Supple without adenopathy.
Lungs: Clear.
ASSESSMENT: Allergic rhinitis.
PLAN:
1. She will try Zyrtec instead of Allegra again. Another option
will be to use loratadine. She does not think she has prescription
coverage so that might be cheaper.
2. Samples of Nasonex two sprays in each nostril given for three
weeks. A prescription was written as well.