Primary Care Coding Alert

Compare your answers to those of our experts.

Nothing helps sharpen your coding skills more than chart coding. So, we put together this chart, and asked two of our experts to code it. Read though the encounter, jot down your answers, then see how they compare.

Chief complaint: An established adult patient is here for a follow-up visit for gastro-esophageal reflux disease (GERD). He was previously seen for abdominal pain, heartburn, nausea, and vomiting.

HPI: Patient still complains of heartburn and also of stomach pain, which moves around and comes and goes, lasting for a few seconds and resolving. Pain level is 8/9. Sometimes his back and right shoulder hurt, too. Has no problem voiding, but appetite is poor. Labs done at previous visit reviewed.

Vital signs: Weight: 133 lb. Height: 5 ft 7 in. BMI: 20.83. Temperature: 98.4°F. Respiration Rate: 18. Oxygen Saturation: 99% on room air at rest. BP1: 115/74. Heart Rate: 89. Rhythm: Regular. Volume: Normal. Character: Normal.

Past Medical History: Hyperlipidemia, prediabetes.

FH: Mother: hypertensive
SH: The patient is married. The patient has never smoked, no caffeine, no alcohol, and no drugs.
ROS: Patient complaints per HPI.
Exam: General: Well developed, well nourished, normal alertness, oriented, no acute distress.
​          Cardiovascular: Regular rate and rhythm, no murmurs, normal heart sounds.
​          Respiratory: Normal breath sounds, no wheezes, no rhonchi, normal chest expansion.
​          Psychiatric/mood: No anxiety, no depression, normal behavior.
​          Gastrointestinal: Soft to touch, no distention, positive bowel sound but mildly tender all over.

Plan of Care Notes: Reviewed previous labs. Ordered abdomen ultrasound for unclear etiology of continual abdominal pain. Amylase and lipase ordered.

Diagnosis:

#1: GERD
​          Continue treatment

#2: Hyperlipidemia
#3: Abdominal pain
​          US of abdomen

Follow-up in two weeks for lab review.

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