Question

IDENTIFICATION: The patient is a 37-year-old Caucasian lady.

CHIEF COMPLAINT: The patient is here today for follow-up (Established patient & established problem.) of lower extremity swelling. (Chief complaint)
HISTORY OF PRESENT ILLNESS: A 37-year-old with a history of dyslipidemia and chronic pain. (Past medical history) The patient is here for follow-up of bilateral lower extremity (HPI: Location) swelling. The patient tells me that the swelling responded to hydrochlorothiazide. (HPI: Modifying factor)
EXAM: Very pleasant, no acute distress (NAD). VITALS: P: 67, R: 18, Temp 98.6, BP: 130/85.
DATA REVIEW: I did review her labs, (Lab reviewed) and echocardiogram. (Echocardiogram review) The patient does have moderate pulmonary hypertension.
ASSESSMENT:
1. Bilateral lower extremity swelling: This has resolved with diuretics; this may be secondary to problem #2.(Possibly due to pulmonary hypertension, but not certain, so code separately.)
2. Pulmonary hypertension: Etiology is not clear at this time, will do a work up and possible referral to a pulmonologist.
PLAN: I think we will need to evaluate the etiology of the pulmonary hypertension. The patient will bescheduled for a sleep study.
What are the CPT® and ICD-10-CM codes reported?
CPT® code: [a]
ICD-10-CM codes: [b], [c]

Answer 1

The specific CPT® and ICD-10-CM codes reported would depend on the services provided during the sleep study and the diagnosis after the workup. Common CPT® codes for sleep studies include 95810, 95811, and 95807, while possible ICD-10-CM codes include I27.20, E87.8, and R60.1.

Step-by-step explanation:

The CPT® code reported for this scenario would depend on the specific service provided during the sleep study and would require more information. However, common CPT® codes for sleep studies include 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist), 95811 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist) and 95807 (Polysomnography; age 6 years or older, sleep staging with 1-3 additional parameters of sleep, attended by a technologist).

The ICD-10-CM codes reported for this scenario would also depend on the specific diagnosis given after the workup. However, possible ICD-10-CM codes to consider include I27.20 (Pulmonary hypertension, unspecified), E87.8 (Other disorders of electrolyte and fluid balance, not elsewhere classified) and R60.1 (Generalized edema).