Emergency Department (ED) sample medical coding chart 1

Chief Complaint & History of Present Illness :  

19 year old male presents for headache.Patient states his symptoms started approximately six days ago with a left sided headache.He describes his pain as a throbbing sensation on the left side of his head and rates the pain as a 4/10.His symptoms got progressively worse and he developed visual disturbances.He had one episode of emesis today.Patient denies fever and ear pain.He notes that he was taking Aspirin and Advil for his symptoms.Patient denies history of migraines and any recent head injuries. Patient’s father had an ischemic stroke.

Medical Decision Making (MDM) :  

19 year old man here with gradual onset migrainous headache.No trauma; no fever or neck stiffness, very unlikely for meningitis and reassuring neuro exam and gradual onset make SAH or mass unlikely.Feeling better here.Plan home migraine meds, clear return precautions, followup in clinic.

ED Diagnosis (Current Problem List) :  

Problem Associated ICD-10-CM Code Status Onset

Migraine None Associated Active

Past Medical History :  

PMH: None

Primary MD: MCC

Surgeries / Procedures: No recent surgery.

Allergies

No Known Drug Allergies

Home Medications

Aspirin-Acetaminophen-Caffeine 250 mg-250 mg-65 mg, 2 tablet orally every 6 hours PRN pain

Ondansetron, 4 milligram orally 4 times per day PRN nausea and vomiting(Duration: 5 days)

Prozac Oral, daily

wellbutrin, daily

Social History

Patient denies tobacco use and alcohol consumption.

Tobacco Use

Review Of Systems

ROS:

IX1 All systems reviewed and found to be negative except those mentioned in the history of present illness.

Vital Signs

Most Recent Set of Vitals:

BP: 128/77 08/29 22:44

Pulse: 90 08/29 22:44

Temp: 37.4 C 08/29 22:44

Resp: 18 08/29 22:44

02 Sat: 100% 08/29 22:44

Calculated BMI: 21.6 08/29 22:44

Additional Vitals:

Triage:

Temp 37.4 C 08/29 22:44

BP 1 128/77 08/29 22:44

Pulse 90 08/29 22:44

Resp 18 08/29 22:44

02 Sat%,PulseOx 100% 08/29/ 22:44

Vitals: Pulse Ox 

02 Source : Room Air 02 Delivery : 02 L/min Fi02 %

Pulse Ox Reading: 100 % Interpretation: Normal Date/Time:

Physical Exam

GENERAL

Vital signs reviewed.

Gen/Psych: Cooperative

Head: Atraumatic, normocephalic

Eyes: Pupils equal, round, and reactive.Eyes nonicteric, noninjected

ENT: Mucous membranes moist, no exudate

Neck: Supple

CV: Regular rate and rhythm, no murmurs

Resp: Clear to auscultation bilaterally.No wheezes, rales or rhonchi

Abd: Soft, nontender

Neuro: Moves all extremities equally, good motor and sensation intact throughout, CN 2-12 grossly intact, gait stable

Skin: No lesions.No rashes.

Medical Decision Making (MDM) :  

19 year old man here with gradual onset migrainous headache.No trauma; no fever or neck stiffness, very unlikely for meningitis

and reassuring neuro exam and gradual onset make SAH or mass unlikely.Feeling better here.Plan home migraine meds, clear

return precautions, followup in clinic.

ED Diagnosis (Current Problem List) :  

Problem Associated ICD-10-CM Code Status Onset

Migraine None Associated Active

CPT code : 99282   

Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making

G43909 Migraine, unspecified, not intractable, without status migrainosus

Emergency Department (ED) sample medical coding chart 2

Chief Complaint & History of Present Illness :  

19 year old female presents to the ED with her mother for drainage of cyst on her right upper gluteal fold.The patient was sent in by Dr..The patient states the cyst has been draining all day.She has not applied any compresses for relief.

She denies allergies.LMP was 3 weeks ago.

Medical Decision Making (MDM) :  

19 Year old female presents to ED with pilonidal cyst /abscess.Patient has been having pain to the sacral region for last few days.Otherwise healthy with no past medical history.On exam, there is active drainage noted from the pilonidal abscess.

Copious pus was drained.There is surrounding cellulitis.Plan to start antibiotics Keflex and Bactrim.Patient is advised to follow up with her PMD next 2 days wound check.Strict return precautions are given.She is in no acute distress and is discharged with

her mother.

ED Diagnosis (Current Problem List)

Problem Associated ICD-10-CM Code Status Onset

Pilonidal cyst with abscess L05.01 – PILONIDAL CYST WITH ABSCESS Active

Past Medical History :  

PMH: Denies

Allergies

No Known Allergies

Home Medications

cephALEXin, 500 milligram orally 4 times per day (Duration: 7 days)

Sulfamethoxazole-Trimethoprim 800 mg-160 mg (DS), 1 tablet orally every 12 hours

Social History

Denies alcohol, illicit drug and tobacco use.Mother at bedside.

Review Of Systems

ROS:

IX1 All systems reviewed and found to be negative except those mentioned in the history of present illness.

Vital Signs

Most Recent Set of Vitals:

BP: 127/79 09/16 21:03

Pulse: 86 09/16 21:03

Temp: 36.8 C 09/16 18:28

Resp: 16 09/16 21:03

02 Sat: 98%(01/m)(Room Air) 09/16 21:03

Calculated BMI: 22.4 09/16 18:28

Additional Vitals:

Triage:

Temp 36.8 C 09/16 18:28

BP 1 139/100 Arm,Upper Lt Sitting NIBP 09/16 18:28

Pulse 115 09/16 18:28

Resp 20 09/16 18:28

02 Sat%,PulseOx 99% Room Air 09/16 18:28

Vitals: Pulse Ox [This section may be copied as needed]

02 Source : Room Air 02 Delivery : 02 L/min FiO2 %

Pulse Ox Reading: 99 % Interpretation: normal Date/Time:

Physical Exam

GENERAL

GENERAL: Awake, alert, oriented x3, no acute distress, well appearing

EYES: PERRL, EOMI

HENT: Trachea midline, nontender, no crepitus, no cervical lymphadenopathy, no meningismus

CVS: 51 S2, regular rate and rhythm, no obvious murmurs

PULMONARY: Bilateral clear lungs, no respiratory distress

ABDOMEN: Soft, nontender, no distension, no guarding or rebound, normal bowel sounds

EXTREMITIES: No swelling, nontender, no deformity

VASCULAR: Pulses equal and intact

SKIN: Cyst right upper gluteal fold, actively draining.

NEURO: A&Ox4, no acute neurological deficits, cranial nerves intact

PSYCH: No suicidal ideation or homicidal ideation, no acute hallucinations

Medical Decision Making (MDM) :  

19 Year old female presents to ED with pilonidal cyst/abscess.Patient has been having pain to the sacral region for last few days.

Otherwise healthy with no past medical history.On exam, there is active drainage noted from the pilonidal abscess.Copious pus

was drained.There is surrounding cellulitis.Plan to start antibiotics Keflex and Bactrim.Patient is advised to follow up with her

PMD next 2 days wound check Strict return precautions are given.She is in no acute distress and is discharged with her mother.

ED Diagnosis (Current Problem List) :  

Problem Associated ICD-10-CM Code Status Onset

Pilonidal cyst with abscess L05.01 – PILONIDAL CYST WITH ABSCESS Active

CPT code : 99282   

Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making

L0501     Pilonidal cyst with abscess

Emergency Department (ED) sample medical coding chart 3

Chief Complaint & History of Present Illness :  

19 year old female presents with urine incontinence onset 09/18/.She denies any hx of surgery.

Medical Decision Making (MDM) :  

This is an otherwise healthy 19-year-old young woman who presents with a day of dysuria, frequency and incontinence.No fever. No flank pain.

Exam is normal.Abdomen is benign.No CVAT.No fever.

Urinalysis is consistent with UTI with 71 WBC, 37 RBC, 2+ leukocyte esterase, negative nitrites.This was sent for culture.

Pregnancy is negative.

Patient is being discharged home with a prescription for Macrobid for her uncomplicated cystitis.She will follow up with the Community Clinic later in the week and agrees to return here if worse.

ED Diagnosis (Current Problem List) :  

Problem Associated ICD-10-CM Code Status Onset

UTI None Associated Active

Past Medical History :  

PMH: none reported

Primary MD: MCC

Allergies

No Known Drug Allergies

Home Medications

Nitrofurantoin (12 hr Macrocrystal form), 100 milligram orally every 12 hours (Duration: 5 days)

Social History

nonsmoker, denies alcohol consumption

Tobacco Use

None Reported : TOBACCO HISTORY

Review Of Systems

ROS:

IX] All systems reviewed and found to be negative except those mentioned in the history of present illness.

Vital Signs

Most Recent Set of Vitals:

BP: 108/67 09/18/ 02:17

Pulse: 64 09/17/ 23:58

Temp: 36.8 C 09/18/ 02:19

Resp: 16 09/18/ 02:17

02 Sat: 99%(Room Air) 09/18/ 02:17

Calculated BMI: 20.2 09/17/ 21:51

Additional Vitals:

TRIAGE:

Temp 36.8 C 09/17/ 21:51

BP 1 113/69 09/17/ 21:51

Pulse 69 09/17/ 21:51

Resp 18 09/17/ 21:51

02 Sat%,PulseOx 100% Room Air 09/17/ 21:51

Vitals: Pulse Ox [This section may be copied as needed]

02 Source : Room Air 02 Delivery : 02 L/min Fi02 %

Pulse Ox Reading: 100 % Interpretation: Normal Date/Time:

Physical Exam

GENERAL

GENERAL: well-appearing, no apparent distress

HEAD: normocephalic, no signs of trauma

HEENT: eyes PERRL, conjunctiva normal, posterior oropharynx normal, mucous membranes moist

NECK: supple, no meningeal signs, no JVD

CHEST: nontender, lungs clear

HEART: regular rate and rhythm

ABDOMEN: soft, nontender, nondistended, no peritoneal signs

BACK: no midline tenderness, no CVAT

EXTREMITIES: no cyanosis, no edema

NEURO: patient is awake and alert, no focal deficits

SKIN: warm and dry

PSYCH: calm, cooperative

Medical Decision Making (MDM) :  

This is an otherwise healthy 19-year-old young woman who presents with a day of dysuria, frequency and incontinence.No fever. No flank pain.

Exam is normal.Abdomen is benign.No CVAT.No fever.

Urinalysis is consistent with UTI with 71 WBC, 37 RBC, 2+ leukocyte esterase, negative nitrites.This was sent for culture.

Pregnancy is negative.

Patient is being discharged home with a prescription for Macrobid for her uncomplicated cystitis.She will follow up with the

Community Clinic later in the week and agrees to return here if worse.

ED Diagnosis (Current Problem List) :  

Problem Associated ICD-10-CM Code Status Onset

UTI None Associated Active

Disposition Decision Date/Time:

# D/C from ED to: Home

CPT code: 99283   

Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making

N390      Urinary tract infection, site not specified