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what is the CPT Code? LOCATION:Inpatient Hospital PATIENT: Madonna Miller PHYSICIAN: Alma Naraquist, M.D. REASON FOR...

what is the CPT Code?

LOCATION:Inpatient Hospital

PATIENT: Madonna Miller

PHYSICIAN: Alma Naraquist, M.D.

REASON FOR ADMISSION: Severe right groin pain.

HISTORY OF PRESENT ILLNESS/PHYSICAL EXAMINATION: As noted in the admission H&P.

LABORATORY DATA: Metabolic panel showed a sodium of 132, chloride 93, potassium 3.2, BUN 24, and creatinine 3.1. May 2, 200X: Comprehensive panel shows a sodium 133, chloride 95, potassium 3.2, BUN 24, creatinine 3.1, alkaline phosphatase 190. Sugars on the day of admission 90 and 203, and on the day of discharge 162 and 181. CPK was normal. CBC showed hemoglobin 11.9 and white count of 16.6: Pro-time was 1.8. Urinalysis showed a moderate amount of glucose and trace bilirubin, otherwise negative. Protein electrophoresis showed a total protein low at 5.1 and albumin low at 2.4.

X-RAY of the right hip and pelvis done showed some demineralization, otherwise no specific fracture. Bone scan showed increased activity in the right hemi-pelvis consistent with fractures in the superior and inferior pubic rami.

HOSPITAL COURSE AND TREATMENT: Madonna was admitted with the right groin pain; severe, persistent. She was continued on her medications, placed at bed rest, and bone scan was ordered. Her nephrologist saw her and managed her fluids. With the return of the bone scan showing a fracture, PT/OT was consulted. She was given codeine for pain and consultation with the orthopedic surgeon. He recommended conservative management with use of a walker. Because of her current living situation, arrangements were made for her to be transferred to the nursing home and recuperate there. With availability, she was transferred to the nursing home.

TRANSFER MEDICATIONS:

Calcitrol 0.25 daily.
Digoxin 0.125 daily.
Epogen 1000 units every Thursday.
Nifedipine XL 30 mg daily.
Potassium 10 mEq t.i.d.
Pravachol 20 mg at bedtime.
Renagel 800 t.i.d.
Coumadin 3 mg daily.
Reglan 10 mg q.i.d.
Acetaminophen 500 mg daily.
Calcium carbonate p.r.n.
Codeine 30 to 60 mg p.o. q.i.d. p.r.n.

DISCHARGE RECOMMENDATION AND FOLLOWUP: She is to continue on her diabetic diet, checking sugars at the nursing home. She is to gradually increase her weight bearing depending upon the pain level in her pelvis. She will be seen by OT and PT.

FINAL DIAGNOSES:

Atraumatic right pelvic fracture.
Diabetes mellitus type II
End-stage renal disease, on dialysis
Coronary artery disease.
Peripheral vascular disease.
Chronic and continuous tobacco abuse.
Long-Term anticoagulation therapy.
Chronic leukocytosis.

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Expert Solution

CPT codes are used to describe tests, surgeries, evaluations, and any other medical procedure performed by a healthcare provider on a patient.

CPT

Organization

Category 1

1 st section - Evaluation & Management (99201 - 99499)

2 nd section - Anaesthesia services (00100 - 01999) (99100- 99140)

3 rd section - Surgery (10021 - 69990 )

4 th section - Radiology services (70010 - 79999)

5 th section - Pathology & Lab services (80048 - 89356)

6 th section -Medicine.(90281 - 99199)(99500 - 99600)

In this senario we can use the all these code.

Sodium of 132, chloride 93, potassium 3.2, BUN 24, and creatinine 3.1. May 2, 200X: Comprehensive panel shows a sodium 133, chloride 95, potassium 3.2, BUN 24, creatinine 3.1, alkaline phosphatase 190. Sugars on the day of admission 90 and 203, and on the day of discharge 162 and 181. CPK was normal. CBC showed hemoglobin 11.9 and white count of 16.6: Pro-time was 1.8. Urinalysis showed a moderate amount of glucose and trace bilirubin, otherwise negative. Protein electrophoresis showed a total protein low at 5.1 and albumin low at 2.4 This will comes under 5 th section

X-RAY of the right hip and pelvis done This will comes under 4 th section

Calcitrol 0.25 daily.
Digoxin 0.125 daily.
Epogen 1000 units every Thursday.
Nifedipine XL 30 mg daily.
Potassium 10 mEq t.i.d.
Pravachol 20 mg at bedtime.
Renagel 800 t.i.d.
Coumadin 3 mg daily.
Reglan 10 mg q.i.d.
Acetaminophen 500 mg daily.
Calcium carbonate p.r.n.
Codeine 30 to 60 mg p.o. q.i.d.

This will comes under 6 th category

Atraumatic right pelvic fracture.
Diabetes mellitus type II
End-stage renal disease, on dialysis
Coronary artery disease.
Peripheral vascular disease.
Chronic and continuous tobacco abuse.
Long-Term anticoagulation therapy.
Chronic leukocytosis.

Nightingale answered 1 year ago

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