Since the patient is a new patient, we’d look for codes in that subsection of E&M. The medical decision-making of prescribing antibiotics by oral administration is relatively low-risk, so this E&M procedure would probably be of low to moderate complexity. This would go with a thorough examination. In our example, since the patient is new, there will be a more involved ‘history’ section of HEM. We can do this by the time spent with the patient, or we can do it by evaluating the amount of work that goes into the HEM.Į&M codes will list the level of intensity (and the time) of the procedure in their description. When you’re selecting E&M codes, you look at the intensity of the evaluation and patient management. The doctor asked the patient about his history, he performed various exams, and he made a medical decision to prescribe antibiotics. Those are each part of the History, Exam, and Medical Decision-Making portions of E&M codes, often abbreviated to HEM. So too are the basic examinations the doctor performed (the thoracic percussion and the use of the stethoscope). You may think that the prescription of medication by the doctor falls into yet another category of procedure, but prescribing a medication is actually part of the E&M process. Secondly, we see that the doctor performed a test on the patient to confirm the diagnosis. Firstly, since a new patient is coming into the doctor’s office with an as-yet unspecified condition, we know it’s an Evaluation and Management (E&M) procedure. We’re taking the long route for the sake of instruction). (Bear in mind that you could also just look up Streptococcus Pneumoniae in the alphabetic index of ICD-10-CM. In this case, there are no subcategories or subclassifications. In that section we’d find “ J13 – pneumonia due to Streptococcus pneumoniae,” which is the code we’re looking for: pneumonia caused by streptococcal bacteria. We’d look to the range J00– J99, for Diseases of the Respiratory System.

So, in order to get the proper diagnosis code, we turn to the ICD-10-CM manual. (Remember, we always code the definitive diagnosis, meaning we wouldn’t code the cough, fever, or any of the other symptoms unless the doctor could come to a definitive diagnosis). The doctor has diagnosed streptococcal pneumoniae in this patient. We can start right away with the most straightforward code: the diagnosis. Let’s start abstracting the information from this medical report. Prescribed patient two weeks of 500mg azithromycin (Zithromax), and scheduled follow-up for next week. Diagnosis of streptococcal pneumoniae confirmed. Obtained blood sample for Antistreptolysin O titer. Percussion test on thorax suggests buildup in lungs. Examination via stethoscope yields heavy rales. Patient presents with chills, headache, cough, fever (101 degrees), difficulty breathing. Patient states he is allergic to penicillin, but has no other outstanding medical history. He’s had a fever, a cough, some slight chest pain, and difficulty breathing. Here’s some context: our patient is in his late 20s and has not seen this doctor before. Let’s start off with a relatively straightforward visit to the doctor’s office. They are presented solely as teaching examples. Some of them may have been simplified for space. Please note that these scenarios, medical reports, and coding examples are all theoretical.

Icd 10 code for cough