KristieStokesCPC
Expert
My doctor coded out the below note (thru our EMR) with the E code E885.9. I need the 800/900 code to bill with this. I am thinking about using 850.5, but I wanted to get feedback from my fellow coders. Please help 
... Thanks
He was dragging some limbs in the yard and tripped and fell and struck his head on the corner of the shed. He cut his head and was uncounsciouness for a period of time. He went to SHH. He waited until several days later to go to the ER. He woke up and felt fine without a bad headache, but did see he had cut his head and bled. Later he thought he would not know if he had internal damage so he went to the UCC 4 days later after thinking about it. He was concerned to have someone look at it to make sure the wound wasn't getting infected. He was sent to the ER. He had a CT of the brain in the ER. The CT showed some changes of strokes. He has a history of high cholesterol. He is on Altoprev and Zetia. He is intolerable to statins. He sees a lipid specialist in Mobile, Alabama. He is not taking the fish oil and we discussed he needs to get back on it. He is frightened about having a stroke because his family history with his mom having a stroke. We talked about the results of his CT scan may be old changes, even as old as from birth, and there is no way to tell how old it is because we have no previous brain CT to compare it to. He is encouraged to try to stay healthy and not focus on the CT results. He doesn't smoke, he quit several years ago.
Current Problems:
Chronic low back pain
Contracture of palmar fascia
Essential hypertension
Hypercholesterolemia
Leg weakness
Allergies:
Penicillins:
Tetracyclines:
Phenobarbital:
Astelin:
Current Medications:
Altoprev 60mg Tablets, Extended Release Take 1 tablet(s) by mouth each evening
Astelin 137mcg/1spray Nasal Spray 2 spray(s) in each nostril bid
Cyclobenzaprine HCl 10mg Tablet one tablet tid
Fluticasone Propionate 50mcg Nasal Spray 1 spray(s) each nostril bid
Nexium 40mg Capsules, Delayed Release Take 1 capsule(s) by mouth daily
Zetia 10mg Tablet Take 1 tablet(s) by mouth daily
OBJECTIVE:
Vitals:
Current: 9/2/2009 9:18:50 AM
Ht: 69.5 inches; Wt: 200 lbs; BMI: 29.11
T: 97.9 F (oral); BP: 137/83 mm Hg (left arm, sitting); P: 83 bpm (left arm (BP Cuff), sitting); R: 17 bpm
Exams:
PHYSICAL EXAM:
GENERAL: well developed, well nourished; well groomed;
E/N/T: EARS: external auditory canal normal; bilateral TMs are normal; OROPHARYNX: oral mucosa is normal; normal palate; normal tongue; posterior pharynx shows post nasal drainage, cobblestoning, and erythema of posterior pharynx;
RESPIRATORY: normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs;
CARDIOVASCULAR: normal rate; rhythm is regular; normal S1; normal S2; no cyanosis; no edema;
SKIN: curved long healing laceration posterior scalp on the right side, it is about 5 to 6 inches long;
NEUROLOGIC: mental status: alert; cranial nerves II-XII grossly intact;
PSYCHIATRIC: appropriate affect and demeanor;
ASSESSMENT:
E885.9 Fall from other slipping, tripping, or stumbling
434.91 Cerebral lacunar infarct
272.0 Hypercholesterolemia
401.1 Essential hypertension
PLAN:
Hypercholesterolemia
Continue current medications,
Essential hypertension
Continue current medications,
CHARGE CAPTURE:
Primary Diagnosis:
E885.9 Fall from other slipping, tripping, or stumbling
Orders:
99214 Office/outpatient visit; established patient, level 4
434.91 Cerebral lacunar infarct
272.0 Hypercholesterolemia
401.1 Essential hypertension
... ThanksHe was dragging some limbs in the yard and tripped and fell and struck his head on the corner of the shed. He cut his head and was uncounsciouness for a period of time. He went to SHH. He waited until several days later to go to the ER. He woke up and felt fine without a bad headache, but did see he had cut his head and bled. Later he thought he would not know if he had internal damage so he went to the UCC 4 days later after thinking about it. He was concerned to have someone look at it to make sure the wound wasn't getting infected. He was sent to the ER. He had a CT of the brain in the ER. The CT showed some changes of strokes. He has a history of high cholesterol. He is on Altoprev and Zetia. He is intolerable to statins. He sees a lipid specialist in Mobile, Alabama. He is not taking the fish oil and we discussed he needs to get back on it. He is frightened about having a stroke because his family history with his mom having a stroke. We talked about the results of his CT scan may be old changes, even as old as from birth, and there is no way to tell how old it is because we have no previous brain CT to compare it to. He is encouraged to try to stay healthy and not focus on the CT results. He doesn't smoke, he quit several years ago.
Current Problems:
Chronic low back pain
Contracture of palmar fascia
Essential hypertension
Hypercholesterolemia
Leg weakness
Allergies:
Penicillins:
Tetracyclines:
Phenobarbital:
Astelin:
Current Medications:
Altoprev 60mg Tablets, Extended Release Take 1 tablet(s) by mouth each evening
Astelin 137mcg/1spray Nasal Spray 2 spray(s) in each nostril bid
Cyclobenzaprine HCl 10mg Tablet one tablet tid
Fluticasone Propionate 50mcg Nasal Spray 1 spray(s) each nostril bid
Nexium 40mg Capsules, Delayed Release Take 1 capsule(s) by mouth daily
Zetia 10mg Tablet Take 1 tablet(s) by mouth daily
OBJECTIVE:
Vitals:
Current: 9/2/2009 9:18:50 AM
Ht: 69.5 inches; Wt: 200 lbs; BMI: 29.11
T: 97.9 F (oral); BP: 137/83 mm Hg (left arm, sitting); P: 83 bpm (left arm (BP Cuff), sitting); R: 17 bpm
Exams:
PHYSICAL EXAM:
GENERAL: well developed, well nourished; well groomed;
E/N/T: EARS: external auditory canal normal; bilateral TMs are normal; OROPHARYNX: oral mucosa is normal; normal palate; normal tongue; posterior pharynx shows post nasal drainage, cobblestoning, and erythema of posterior pharynx;
RESPIRATORY: normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs;
CARDIOVASCULAR: normal rate; rhythm is regular; normal S1; normal S2; no cyanosis; no edema;
SKIN: curved long healing laceration posterior scalp on the right side, it is about 5 to 6 inches long;
NEUROLOGIC: mental status: alert; cranial nerves II-XII grossly intact;
PSYCHIATRIC: appropriate affect and demeanor;
ASSESSMENT:
E885.9 Fall from other slipping, tripping, or stumbling
434.91 Cerebral lacunar infarct
272.0 Hypercholesterolemia
401.1 Essential hypertension
PLAN:
Hypercholesterolemia
Continue current medications,
Essential hypertension
Continue current medications,
CHARGE CAPTURE:
Primary Diagnosis:
E885.9 Fall from other slipping, tripping, or stumbling
Orders:
99214 Office/outpatient visit; established patient, level 4
434.91 Cerebral lacunar infarct
272.0 Hypercholesterolemia
401.1 Essential hypertension
