Question

Directions: Read through this progress note on Roy A. Takashima. Abstract information from the note about the subjective symptoms, objective findings, and diagnoses. List the diagnostic and procedure codes you think this case would warrant.

The Case:

Takashima, Roy A.

October 5, 20xx

Patient presents with many things going on. First, he's had no difficulties after the feral cat bite, and the cat was normal on quarantine. He seemed to be recovering from the flu but is plagued with a persistent cough and pain down the center of his chest attributed to bronchitis without fever or grossly discolored phlegm. Physical examination shows expiratory rhonchi and gross exacerbation of his cough on forced expiration. Spirometry before and after bronchodilator was remarkably good: he is symptomatically improved with a Proventil inhaler, which he is given as a sample. I don't think other antibiotics would help. His reflux is under good control with proprietary antacids with a clear examination. He has several areas of seborrheic keratoses on his face and head that need attention. Finally, in follow-up, he needs a complete physical examination. - Ting Cho, MD

Diagnosis, Influenza and acute bronchitis

Question:

Objective findings on this case?

Answer 1

ICD-10-CM code for Influence due to other identified Influenza virus with other respirstory manifestation is J10.1

ICD-10-CM code for Acute Bronchitis is J20.8

ICD-10-CM code for Seborrheic Keratosis is L82.1

ICD-10-CM code for gastroesophageal reflex disease without esophagitis is K21.9

CPT code for Spirometry is 94010.

Objective findings are the visible measurable findings obtained by a medical examination, tests or diagnostic imaging. In this case, objective finding is Seborrheic kerotosis on face and head.