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Medical Billing and Coding, ICD-10-CM, ICD-10-PCS, CPT, HCPCS, etc.
Viewing:  Dec 16, 2017

Code-A-Note™  instantly code provider notes

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Patient Information

Notes/EMR  (Paste notes here.)

ASSESSMENT: Chest pain.ASSESSMENT: The patient is a 40-year-old white male who presents with a chief complaint of "chest pain".ASSESSMENT: The patient is diabetic and has a prior history of coronary artery disease. The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent. The severity of the pain has progressively increased. He describes the pain as a sharp and heavy pain which radiates to his neck and left arm. He ranks the pain a 7 on a scale of 1-10. He admits some shortness of breath and diaphoresis. He states that he has had nausea and 3 episodes of vomiting tonight. He denies any fever or chills. He admits prior episodes of similar pain prior to his PTCA in 1995. He states the pain is somewhat worse with walking and seems to be relieved with rest. There is no change in pain with positioning. He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain. The patient ranks his present pain a 4 on a scale of 1-10. The most recent episode of pain has lasted one-hour. Acute Inferior Myocardial Infarction.ASSESSMENT: The patient is moderately obese but he is otherwise well developed and well nourished. He appears in moderate discomfort but there is no evidence of distress. He is alert, and oriented to person place and circumstance. There is no evidence of respiratory distress. The patient ambulates without gait abnormality or difficulty.Normocephalic / atraumatic head. Pupils are 2.5 mm, equal round and react to light bilaterally. Extra-ocular muscles are intact bilaterally. External auditory canals are clear bilaterally. Tympanic membranes are clear and intact bilaterally.Neck: No JVD. Neck is supple. There is free range of motion and no tenderness, thyromegaly or lymphadenopathy noted.Pharynx: Clear, no erythema, exudates or tonsillar enlargement.Chest: No chest wall tenderness to palpation. Lungs: Clear to auscultation bilaterally. Heart: irregularly-irregular rate and rhythm no murmurs gallops or rubs. Normal PMIAbdomen: Soft, non-distended. No tenderness noted. No CVAT.Skin: Warm, diaphoretic, mucous membranes moist, normal turgor, no rash noted.Extremities: No gross visible deformity, free range of motion. No edema or cyanosis. No calf / thigh tenderness or swelling.ASSESSMENT:The patient's chest pain improved after the sublingual nitroglycerine and completely resolved with the Nitroglycerin Drip at 30 ug / Minute. He tolerated the TPA well. He was transferred to the CCU in a stable condition


Recommendations  (Click on a code to Choose it.)

729.5 - Pain in limbView Code Info
723.1 - CervicalgiaView Code Info
782.8 - Changes in skin textureView Code Info
786.05 - Shortness of breathView Code Info
787.01 - Nausea with vomitingView Code Info
447.9 - Arterial disease NOSView Code Info
414.9 - Chr ischemic hrt dis NOSView Code Info
786.50 - Chest pain NOSView Code Info
787.02 - Nausea aloneView Code Info
787.03 - Vomiting aloneView Code Info
410.9 - Unspecified siteView Code Info
410.4 - Acute myocardial infarction; of other inferior wallView Code Info
No codes to show.
J3490 - Drugs unclassified injectionView Code Info
  Non-specific Code    View Code Info    Remove Code

Chosen Codes

HCPCS J3490 - Drugs unclassified injectionView Code Info
ICD9 729.5 - Pain in limbView Code Info
ICD9 782.8 - Changes in skin textureView Code Info
ICD9 787.01 - Nausea with vomitingView Code Info

Code Checker

General Messages:
OKNo General Issues
Procedure Code: 99201
OKNo Issues
Procedure Code: J3490
OKNo Issues

About Code-A-Note™

Code-A-Note's Concept Extractor analyzes the volumes of information contained in an EMR's text fields and uses the three rule bases created from the ICD-9, ICD-10, CPT®, and HCPCS code sets, and then applies additional filter and data resources from Find-A-Code's digital coding library. The system increases coder accuracy and efficiency, saving you both time and money.

The professional coder selects appropriate codes from those suggested by the software. Selected codes can then be validated using Find-A-Code's up-to-date code validation tools. Simply click the "Check Codes" button:

Selected codes are instantly checked for Medical Necessity, NCCI Edits, MUE Edits (gender, age, pregnancy, etc.), active/inactive codes, and proper Place of Service values.

This results in claims that are more compliant and accurate. Because of the increased accuracy in coding, Code-A-Note greatly reduces the number of claims rejected, denied, or suspended. Code-A-Note puts your clinic or office on the fast track for coding and claims processing.

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