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:
Spirometry code?
Ans) Pulmonary Function Testing codes:
Spirometry - CPT codes for Spirometry include 94010, 94011, 94012,
94060, 94070, 94150, 94200, 94375, 94726 and 94727.
- CPT code 94060 (bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) describes a diagnostic test that is utilized to assess patient symptoms that might be related to reversible airway obstruction. It does not describe treatment of acute airway obstruction.
- Procedure CPT Code:
Pulmonary Function Testing—no bronchodilator 94010
Pulmonary Function Testing pre and post bronchodilator- 94060
Aerosol treatment (includes demonstration)- 94640
Demonstration- 94664
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