coding files

CHART NOTE CODING EXERCISES

Name: _______Nirali Desai______________________________

Instructions: Please use the coding worksheet and write down all of the ICD10 Codes for each diagnosis and the E/M CPT code for the visit. Please write your logic. You will be graded on effort and logic. Please post in the BB discussion area – Coding homeworkExample #1 DONE – Start with #2Return Visit Patient: Doe, Jane

History: AA1234Date: November 1,200X

S: Patient states her chest pain a couple of nights ago was relieved by ginger ale, she now says the pain lasted a few minutes and she’s had no chest pain since. She says she is feeling fine and wants to continue living with her husband. In discussion with her husband, the family is very concerned about the patient’s increasing levels of dementia and confusion. Husband questions whether he will be able to handle her, and the ABC Retirement Home first wanted to put her in XYZ Care, which is the nursing home, but then decided she would do fine in assisted living. Notes from ABC’s infirmary show that she does wander a lot and has disturbed other patients. Current medications: Multivitamin, Dulcolax, Calcium 800 mg daily, Synthroid 0.1 mg daily, Norvasc 2.5 mg daily, Aricept 10 mg at hs. Needs a flu shot.

O: Lungs are clear. Heart RRR without murmur. No pedal edema. Recent TSH was normal at 1.2.

A: 1. Alzheimer’s ICD-10_______________2. Hypothyroidism. ICD-10_______________3. Chest pain, resolved ICD-10_______________

P: 1. In discussion with the family decided to place the patient in the assisted living facility. He will go and have lunch and dinner with her as he wishes, and we will reassess when she comes back in January.2. Refill Synthroid 0.1 mg #30, 1 daily, 6 refills.3. Reassurance that episode was not consistent with angina, though we will be alert for other episodes and do further evaluation if indicated.

E/M CPT code:___________

Example #2Return Visit Patient: Doe, John

Established History: AA1234Date: January 1, 200X

S: He comes in today for continued bronchitis symptoms, cough productive of yellow-green symptoms, since last seen 2 days ago.

CC/HPI: LOCATES = 3ROS= 0PMH/FH/SH =0

Hx: PF EPF Detailed CompHPI: 1–3 1–3 4+ 4+ROS: 0 1 2–9 10+PFSH: 0 0 1 2(est) or 3(new)

O: On exam he has rhonchi, particularly in the left chest, faint forced expiratory wheezing. Not tachypneic at rest. *LUNG and CV exam

PF EPF Detailed Comp

1 2–7 2 -7 detailed 8+ 1-5 6 -11 12 All 1 1 1 detailed 8

A: Persistent bronchitis. ICD-10___J40____________

P: Start Septra DS, 1 twice daily for 7 days. Albuterol MDI 2 puffs every 6 hours, out of work today and tomorrow. Return one week.

MDM: Sfwd. Low Mod. HighDx./Mgmt: 0-1 2 3 4+Data: 0-1 2 3 4+Risk: Min. Low Mod High

E/M CPT code:__99212_________

ESTABLISHED PATIENT CPT codes require 2 of 3 key

E/M Code History Exam MDM Face-to-face

99211 supervision only

supervision only

Stfrwd 5 min.

99212 PF PF Stfrwd 10 min.

99213 EPF EPF Low 15 min.

99214 D D Modera 25 min.

99215 C C High 40 min.

Example #3Return Visit Patient: Doe, Jane

History: AA1234Date: January 1, 200X

S: Patient is a 73 year old lady who comes in for follow up of her diabetes and hypertension. She is on Metformin 500 mg BID, aspirin 81 mg daily, hydrochlorothiazide 25 mg daily, atenolol 50 mg daily, lisinopril 5 mg daily. She is doing very well and has been active during the holidays with her children. Her weight is stable. Denies any low blood sugars, they are running 110 to 170, no hypoglycemic episodes. She had a recent retinal exam which was normal.

CC/HPI: LOCATES = 1 ROS=0 PMH/FH/SH = 2


O: WT: 115 BP: 122/78. Accucheck 132. Chest clear to auscultation. Cardiac exam: regular rate and rhythm without any murmurs, rubs or gallops. There are no carotid bruits. Extremities without cyanosis, clubbing or edema. Last glycated hemoglobin was 6.7 5 months ago. *vitals, LUNG, and CV exam



A: 1. Hypertension, well controlled ICD-10____I10___________2. Diabetes, well controlled. ICD-10____E11.9___________

P: 1. Continue current regimen.2. Recheck Hgb A1C when she returns next month for annual exam.


E/M CPT code:___99213________


History Exam MDM Face-to-face


supervision only

Stfrwd 5 min.



99214 D D Moderat 25 min.


Example #4Return Visit Patient: Doe, Janeestablished History: AA1234

Date: January 1, 200X

Problem: depressionS: Ms. Doe states she feels noticeably better. Her mood is improved; she

is happier and has been laughing some lately, which is unusual for her. She has been actively exercising either on a Nautilus machine or in swimming. However, she is very upset with the side effects of Effexor (decreased libido, sexual dysfunction).

O: WT: 165 T 98.8 BP: 124/80. Animated, much more relaxed. Not overtly anxious or depressed. *vitals and PSYC

A: Much less depressed, sexual dysfunction as described. ICD-10___F32.3____________

P: Extended discussion with patient who agreed to discontinue Effexor and go back to previous medication (Prozac 20 mg daily). Return in 10-14 days for follow-up.

Problem: shoulder painS: Patient complaining of right shoulder pain since increasing her

exercise regimen.

O: Tender over the insertion of the biceps on the right and tenderness on adduction of the arm and on abduction as well. No other tenderness or crepitus noted. *MS exam

A: Probable tendonitis from overuse syndrome. ICD-10__M75.22____________

P: Rest, ice, Advil as tolerated. Referred for PT.

Problem: back pain, neck painS: Patients states she has a history of scoliosis and cervical pain for many

years. The symptoms seem to have worsened lately. Patient describes occasional paresthesias into the hand and into the feet. She has been to DOs in the past, but is willing to try a trial of PT.

O: Moderate tenderness on palpation of the cervical spine. Back is slightly tender to palpation in the paralumbar area. No S1 tenderness or tenderness over the sciatic notch. SLR negative. Sensory motor exam and gait WNL. *MS exam

A: Cervical and lumbar pain with occasional radicular symptoms.ICD-10__M54.6, M54.2_____________

P: C-spine series. Referred to PT.

Multiple codes

Hx: PF EPF Detailed Comp HPI: 1–3 1–3 4+ 4+ROS: 0 1 2–9 10+ PFSH: 0 0 1 2 (est) or 3 (new)



MDM: Sfwd. Low Mod. High Dx./Mgmt: 0-1 2 3 4+ Data: 0-1 2 3 4+ Risk: Min. Low Mod High

E/M CPT code:___99214_______________




supervision only

Stfrwd 5 min.





Example #5New Patient Patient: Doe, John


S: Patient comes in complaining of back pain. He’s 28 years old. Injured his back 4 years ago splitting wood. Since then, he’s had intermittent episodes of back pain. It’s now becoming more constant. Radiates down both buttocks. There’s no true numbness, weakness in his legs. He’s tried a waterbed; it’s helped some of the pain. Often it is worse when he first gets up in the morning. He’s been to chiropractic in the past; it was not too effective for him. He’s taking Advil; he gets some relief for the pain, but he’s having to take it daily. He was told by the chiropractor that he had an abnormality, “an unseparated vertebra from the sacrum.” Denies bowel or bladder symptoms.

CC/HPI: LOCATES = 6ROS= 2PMH/FH/SH = 2

Hx: PF EPF Detailed CompHPI: 1–3 1–3 4+ 4+ROS: 0 1 2–9 10+

PFSH: 0 0 1 2(est) or 3(new)

O: He has tenderness up to the upper lumbar region. There is no deformity, no scoliosis. There is some painful flexion, limited flexion. Reflexes symmetric bilaterally. Negative straight leg raising. Good hip range of motion. *MS exam



A: Lumbosacral back pain, chronic strain. ICD-10___M54

P: Physical therapy. Continue the Advil for now. Return for health maintenance; will obtain complete medical history at that visit.


E/M CPT code:__99201_________

NEW PATIENT CPT codes require 3 of 3 key

E/M Code



99202 EPF EPF Stfrwd 20 min.

99203 D D Low 30 min.

99204 C C Moderat 45 min.




S: Problem #1: Closed head injury. The patient is an 86 y.o. female who last week fell backwards in a chair, striking the occipital skull. She states she did not lose consciousness; does seem to have a good memory of the event, but since that time has had quite a bit of head pain. Occasional dizziness which is fleeting and resolves spontaneously, not associated with movement. Problem #2: GI upset. The patient has been seen twice in the last week for frequent soft stools, GI upset, and nausea. She has not had overt diarrhea, nor has she vomited. Not aware of any change in urine or stool color, denies dietary changes or recent travel.

CC/HPI: LOCATES = 4 ROS= 2 PMH/FH/SH = 2


O: Problem #1: Well developed, well nourished, slightly confused-appearing 86 y.o. in no acute distress. Mini mental status exam benign. CN II—XII intact. Strength intact and DTR’s 2+ and symmetric throughout. Romberg negative.Problem #2: Bowel sounds are normal. Abdomen is soft, flat, tender in the right upper quadrant. There is a well-healed cholecystectomy scar present. The liver tip is felt, 2 to 3 cm below the right costal margin and this is tender. Clean catch urinalysis is negative, including bilirubin. CBC is unremarkable. *Gen, NEURO, ABD exams



A: Problem #1: Closed head injury, question subdural hematomaICD-10____S09.90 ___________Problem #2: GI upset, question heptatitis ICD-10__K30_____________

P: Problem #1: She is referred for a CT of the head and will follow up with her PCP Dr. Smith following this.

Problem #2: Chem-16, follow up with Dr. Smith. Given 3 hemoccult cards as these have not been checked in 2 and a half years.


E/M CPT code:_99214__________




supervision only

Stfrwd 5 min.





Example #7Return Visit Patient: Doe, JaneEstablished History: AA1234


S: Patient six months ago was seriously ill at ABC Hospital with ischemic bowel disease and required laparotomy, bowel resection, reanastomosis. She still has occasional episodes of diarrhea, but she has been regaining her weight with good nutrition. She is doing her own wound care, and has not gone back to work due to risk of injury to abdomen. Unfortunately, she has resumed smoking.

She reports she continues to do well with her diabetes, using NPH 24 units and denies any hypoglycemia.

CC/HPI: LOCATES = 3 ROS=0 PMH/FH/SH = 2


O: WT: 123 BP: 120/82 T: 97.6 Appears well, odor of tobacco present. Lungs clear and heart without murmurs. No pedal edema. Superior portion of the wound shows two areas of ulceration with good granulation, dressing is clean and dry. *vitals, GEN, LUNG, CV, ABD exams



A: Diabetes, acceptable control ICD-10_E10.9______________Excellent recovery from serious bowel ischemia ICD-10__K55.0_____________Tobacco abuse ICD-10___Z72.0____________

P: Applauded patient for excellent wound care and nutrition with good weight gain. Importance of smoking cessation discussed. Return to clinic fasting for Hgb A1C and lipids, schedule return visit in one month. Follow up with Dr. Smith as scheduled.


E/M CPT code:____99213_______




supervision only

Stfrwd 5 min.





Example #8Return Visit Patient: Doe, Johnestablished History: AA1234


S: Mr. Doe presents today with a 4-week history of intermittent shortness of breath which is occurring more frequently. He primarily gets his symptoms at nighttime when he lays down. He states he has to gasp for breath, but after sitting up for awhile the symptoms usually subside. He is then able to lie down and go to sleep without difficulty. The symptoms have occurred more frequently lately. He is not getting them during the day and they are not related to exertion. He admits to eating a bedtime snack every night and has been taking ibuprofen 800 mg tid until the past week, and has now cut back to 600 mg twice a day. He drinks lots of coffee as well as citrus and tomato juice. He has been taking an 81 mg aspirin daily as well.

He had athroscopic knee surgery a few months ago. The week after the knee surgery he had left calf pain but no swelling, and he reports the surgeon initially was concerned he could have a blood clot, but apparently ruled that out.



O: WT: 223 BP:120/80. P: 88 R: 18. Chest is clear to auscultation. Cardiac normal S1, S2, no murmurs or gallops. Abdomen benign with active bowel sounds. Extremities: no edema. No JVD. EKG: normal sinus rhythm, no acute ST-T changes. O2 saturation 98%. Chest X-ray appears benign. *vitals, LUNG, CV, ABD exams



A: Probable GERD ICD-10___K21.9____________

P: Stop all NSAIDs and symptom-provoking foods as noted above. Ranitidine 300 mg BID. Tylenol as needed for pain. Follow up visit in 2 weeks or sooner if no resolution of symptoms. Will review Radiology interpretation of Chest X-ray.


E/M CPT code:__99214_________




supervision only

Stfrwd 5 min.



99214 D D Moderate 25 min.



Date: October 15, 200X

S: This 89 y.o. lady saw Dr. Smith 3 months ago for headache and nausea. Wants a flu shot today, and needs refills of her medications. Her only problem is her bladder, and she seems to do best on flavoxate 100 mg 3 times a day, and wants a prescription for that. She also takes atenolol 50 mg daily for benign essential tremor. She has not had a pap smear in years and has not had an abnormal one. Last physical exam was last year. Had pneumococcal vaccine in 1995, tetanus booster 3 years ago, thyroid checked last year.

Also suffers from dry scaling skin on her legs. Says her son found her a cream with 0.1% triamcinolone and emollient worked pretty well, and would like some more.

CC/HPI: LOCATES = 0 ROS: 0PMH/FH/SH = 3


O: WT: 137 BP: 128/76. Alert 89 year old lady who appears younger than her stated years. Intention tremor noted. Skin: reveals multiple scaling patches of lower legs and forearms, loss of skin elasticity. *Vitals, GEN exams



A: Benign intention tremor ICD-10_G25 ______________Bladder spasms/incontinence ICD-10_____R32__________

P: Atenolol 50 mg #30, 1 daily, 11 refills.Flavoxate 100 mg #90, 1 three times a day.Flu vaccine today


E/M CPT code:_99213__________




supervision only

Stfrwd 5 min.





Example #10Return Visit Patient: Doe, Johnestablished History: AA1234


S: 26 year old man returns for new problem of urethral discharge. He reports that yesterday he noted a small amount of urethral discharge, which became increasingly copious, and today he notes some swelling of the penis. He is a software developer and is married, but reports having intercourse with a commercial sex worker while attending a convention in Hawaii a week ago, and did not use condom during this sexual encounter.



O: BP 130/86 T: 98.8 Alert, anxious male in mild to moderate distress. There is no inguinal lymphadenopathy. Testicles without masses or swelling. Penis is uncircumcised with moderate edema; purulent discharge is noted from the urethra. Gram stain is positive for gram negative intracellular diplococci. *vitals/Gen, GU



A: Gonorrhea ICD-10__A54.0_____________

P: Cipro 500 mg PO X 1, doxycycline 100 mg BID X 7 days. GC culture. Patient to notify wife and understands she must be treated regardless of symptoms. HIV counseling and consent, RPR and HIV testing. Face to face time with the patient 30 minutes, greater than 50% of which was spent in counseling the patient regarding STD, safer sex, and condom use.


E/M CPT code:___99213________




supervision only

Stfrwd 5 min.





Example #11New Patient Patient: Doe, James


Subjective:

Chief Complaint: “I’ve had this headache” X 2 days

History of Present Illness: Mr. F. is a 22-year-old male construction worker who is presenting with

a severe throbbing pain on the right temple area of his head. The pain began 2 days ago on the job in the heat. It is relieved with Advil and made worse during exertion and heat. He has never had headaches like this before

He has no fever, chills, sweating, nausea, vomiting, rash, or photophobia. The patient ranks the pain a 5 on a scale of 10.

Nothing has alleviated the pain and it has remained constant. Pertinent ROS:General – See HPI. Patient denies night sweats. Head – See HPI.Psychiatric – Patient denies any past Hx of psychiatric problems depression, loss of vegetative function or substance abuse.Neurological – See HPI. Denies seizures, weakness, head trauma, stroke, or other neurological symptoms.

Past Medical History: Allergies- noneHospitalizations: - noneImmunizations- Up to date Illness – No major IllnessesSurgeries – Wisdom teeth excised in February 2006Trauma - noneOral Med- daily vitaminReproductive Hx- noneYouth Illness- Chicken Pox

Family History: Parents, siblings in good health. No history of headaches, migraines in family or household members

Social History: Patient is a 22-year-old full time construction worker. Has a strong family support system in addition to a healthy relationship with his wife. Denies smoking, street drugs, and ETOH use. He maintains good nutrition and exercise.

CC/HPI: LOCATES = 7ROS=4

PMH/FH/SH = complete FH and SH

Hx: PF EPF Detailed CompHPI: 1–3 1–3 4+ 4+ROS: 0 1 2–9 10+PFSH: 0 0 1 2 (est) or 3(new)

Objective: VS: PB 120/ 75 Pulse 75, Resp 14, Temp 37.4Gen : Oriented x 3 No acute distress, well hydrated, no rashes or lesions, No pallor.Eye: PERRLA, EOM full, Visual Fields intact Fundus: Normal, HENT: Head scalp no lesions or tenderness, Ear TM clear hearing WNL, Mouth - No lesions or inflammation, no carriesNeck: Supple, ROM WNL no adenopathy , no thyromegallyNeuro : CN 2 – 12 intact, Motor, Sensory Cerebellar all WNL, Reflexes all 2+ symmetric*vitals/GEN, HEENT, NECK, NEURO exams



Assessment: 1. Migraine Headache ICD-10________G43.909 ______________________

Plan: Dx - MRI and follow-up in 1 week ICD- 10__B030Y0Z_________________________Rx – Symatriptan 50 mg PO also Napoxen 325mg BID Patient Education – Educate about hydration in the heat, and about migraines


E/M CPT code:__99203_________

NEW PATIENT CPT codes require 3 of 3 key

E/M Code



99202 EPF EPF Stfrwd 20 min.

99203 D D Low 30 min.

99204 C C Moderat 45 min.


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