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**Hospital Progress Note**

**Subjective:**
- Patient is without complaint.
- She states she feels much better.
- No vomiting or diarrhea.
- She did have a bowel movement yesterday.
- No shortness of breath, no chest pain.
- The patient and daughter were questioned again about her cardiac history. She denies any cardiac history.
- She has no orthopnea, no dyspnea on exertion, no angina in the past, and she has never had any heart problems in the past.
- Case discussed yesterday with Dr. Williams, and I am waiting to find out about her surgery date.

**Objective:**
- **Vital Signs:**
- T-max: 99.6°F
- T-current: 98°F
- Pulse: 72
- Respirations: 18
- Blood pressure: 154/65
- O2 saturation: 96% on room air
- Accu-checks: 113, 132, 96, 98
- **General:**
- No apparent distress, oriented x3, pleasant Spanish-speaking female.
- **Head, Ears, Eyes, Nose, Throat (HEENT):**
- Normocephalic, atraumatic.
- Oropharynx pink and moist.
- Left eye has sclera erythema.
- Pupils equal, round, and reactive to light accommodation (PERRLA).

**Laboratory Data:**
- C Diff-toxin negative.
- Sodium: 129
- Potassium: 3.4
- Chloride: 96
- CO2: 27
- Glucose: 72
- BUN: 12
- Creatinine: 0.6
- Urine culture positive for E. coli, sensitive to Levaquin.

**Assessment:**
1. Cholelithiasis
2. Cystitis
3. Conjunctivitis
4. Hyponatremia
5. Hypokalemia
6. Diabetes mellitus type 2
7. Hypertension

**Plan:**
- If the patient is not to go to surgery today, will feed the patient and likely discharge her if she tolerates a regular diet.
- Will add Norvasc 5 mg p.o. daily.
- Also, pleural effusion, small. Will repeat a chest x-ray PA and lateral this morning to evaluate that.

**Question:**
What are the CPT® and ICD-10-CM codes reported?

Answer :

The CPT® code for the progress note is 99233 for subsequent hospital care per day. Relevant ICD-10-CM codes include K80.20 for cholelithiasis without obstruction and several others for associated conditions. These codes are essential for proper medical documentation and billing.

Based on the provided hospital progress note, here are the CPT® and ICD-10-CM codes reported:

Since the question pertains to a progress note rather than a specific procedure, a relevant CPT® code is 99233 for subsequent hospital care per day, which includes at least two of the following three key components: a detailed interval history, a detailed examination, or medical decision-making of high complexity.

ICD-10-CM Codes:

  1. K80.20 for cholelithiasis without obstruction
  2. N30.00 for acute cystitis without hematuria
  3. H10.9 for conjunctivitis, unspecified
  4. E87.1 for hyponatremia
  5. E87.6 for hypokalemia
  6. E11.9 for Type 2 diabetes mellitus without complications
  7. I10 for essential (primary) hypertension

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Rewritten by : Barada

CPT codes are based on procedures performed, which are not detailed in the provided scenario, while ICD-10-CM codes are based on the patient's diagnoses: Cholelithiasis (K80), Cystitis (N30.00), Conjunctivitis (H10.9), Hyponatremia (E87.1), Hypokalemia (E87.6), Diabetes mellitus type 2 (E11), Hypertension (I10), and Pleural effusion (J90). Accurate coding requires specific details and adherence to guidelines.

The patient's progress note presents various clinical findings and considerations for their medical management. The CPT (Current Procedural Terminology) codes are used to describe the medical, surgical, and diagnostic services provided to the patient, and would depend on the specific procedures or services performed, which are not detailed in the scenario provided.

The ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) codes reflect the patient's diagnoses based on the assessment noted in the progress note, including:

  • Cholelithiasis: K80
  • Cystitis: N30.00 (assuming acute cystitis, as the specific type is not noted)
  • Conjunctivitis: H10.9 (unspecified conjunctivitis)
  • Hyponatremia: E87.1
  • Hypokalemia: E87.6
  • Diabetes mellitus type 2: E11
  • Hypertension: I10
  • Pleural effusion (as mentioned, but not listed as part of the assessment): J90

Additionally, diagnosis codes should be verified for the highest specificity based on the available documentation.