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Chief Complaint: Cough and fever
Subjective: Forty-four y/o female (new patient) complains of cough and fever. The current episode started two days ago. The cough is nonproductive. Exposure to COVID four days ago at work. Associated symptoms include fever, dyspnea on exertion, fatigue, body aches, nasal congestion, and nausea. Pertinent negatives include no chest pain, palpitations, headaches, or orthopnea. Her symptoms are alleviated by OTC cough suppressant. There is no history of COPD.
Review of Systems:
Constitutional: Positive for fatigue. Negative for chills.
HENT: Positive for sinus congestion.
Eyes: Negative.
Cardiovascular: Positive for dyspnea on exertion. Negative for chest pain.
Respiratory: Positive for cough. Negative for shortness of breath at rest.
Skin: No rash.
Musculoskeletal: Negative for myalgias.
Gastrointestinal: Positive for nausea. Negative for diarrhea and vomiting.
Neurological: Negative for headaches.
Past Medical History:
Social History:
Packs/day: 0.50 X 25 years
Types: Cigarettes
Objective:
BP 134/89 (BP Location: Right arm, Patient Position: Sitting) | Pulse 112 | Temp 101.6 °F (Tympanic) | Resp 20 | Ht 5′ 5″ (1.549 m) | Wt 139 lb (54 kg) | SpO2 95%
Physical Exam:
Constitutional:
General: She is not in acute respiratory distress.
Appearance: She is well-developed. She is mildly ill-appearing.
HENT:
Nose: Mucosal edema present. No congestion.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: No posterior oropharyngeal erythema.
Neck:
Vascular: No JVD.
Cardiovascular:
Rate and Rhythm: Tachy rate and regular rhythm.
Heart sounds: Normal heart sounds.
Musculoskeletal:
Right lower leg: No edema.
Left lower leg: No edema.
Pulmonary:
Effort: Pulmonary effort is normal. No respiratory distress.
Breath sounds: No stridor. Examination of the lung fields reveals rhonchi. Rhonchi (Diffuse mild rhonchi bilaterally. Coarse cough.) present. Rales right lung field. No wheezing.
Skin:
General: Skin is warm and dry.
Neurological:
General: No focal deficit present.
Mental Status: She is alert.
Psychiatric:
Behavior: Behavior normal.
Radiology interpretation:
I personally viewed the two view CXR which shows an infiltrate in the right middle lobe. No mass or pneumothorax.
Lab orders placed this encounter:
POCT COVID test is negative
POCT Influenza test is negative for type A & B.
Impression / Plan:
See specific instructions and follow-up as given to the patient caregiver below. We discussed the risk and benefits of taking amox/clav including side effects and allergic reactions.
Discussed with the patient the need for smoking cessation. She quit about three years ago with Wellbutrin for six months. She will contact her PCP for further discussion/management of tobacco use.
Follow-up with your PCP this week. Go to the ED if symptoms worsen. Take OTC Tylenol PRN for fever and muscle/body aches. Increase fluids and plenty of rest.
New Prescriptions:
Albuterol sulfate HFA 108 (90 Base) MCG/ACT inhaler
Commonly known as: PROVENTIL HFA
Two puffs, Inhalation, every six hours as needed
Amox/clav 875mg
Take one pill by mouth twice daily for 10 days
Number and Complexity of Problems Addressed
The patient complains of fever, cough, dyspnea on exertion, fatigue, nausea, and body aches. Fever at 101.6 and HR of 112 meets the criteria for SIRS (Systemic Inflammatory Response Syndrome). This would be considered an “acute illness with systemic symptoms” moderate, Level 4. If the patient had fever, cough, body aches, nausea, fatigue but did NOT meet SIRS criteria, most coders would still consider this “systemic symptoms” and code at Level 4, but documentation is key. If this patient had been sent to the ED, it still would be Level 4. If the patient was hypoxic or looked moderate to severely ill, it would be a Level 5. Again, it comes down to documentation.
Amount and/or Complexity of Data to be Reviewed and Analyzed
Two POCT were ordered (COVID and Influenza) and a chest X-ray. We do not count the chest X-ray as a point since your company most likely bills for either the technical or professional component. If your organization does not bill for any component of the X-ray, then it would count as one point. The 2 POCT meet the criteria for Category 1 in the Complexity of Data, low, Level 3.
Risk of Complications and/or Morbidity or Mortality of Patient Management
Prescription medications (Augmentin and Albuterol) were prescribed. This would meet the criteria for moderate, Level 4 risk. The risk section of the MDM table, per the guidelines, is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. It is not specific to the patient’s condition but to the risk of patient management.
Two of the three elements of MDM need to be met when choosing your level of service. We successfully met Level 4 criteria in the Problems Addressed and Risk categories, so this is a 99204.