Sure! Here’s an example of a chart with CPT code 99284 for a patient who visited the emergency department:
Patient Name: John Smith
Date of Service: 04/13/2023
Reason for Visit: Chest pain and shortness of breath
History of Present Illness: John is a 45-year-old male who presents to the emergency department with complaints of chest pain and shortness of breath. The symptoms started suddenly about an hour ago while he was watching television. He describes the pain as a tightness in his chest that radiates to his left arm. He also reports feeling short of breath and lightheaded.
Physical Exam:
- Vital signs: Blood pressure 140/90 mmHg, heart rate 110 bpm, respiratory rate 20 bpm, oxygen saturation 94% on room air.
- General: Alert and oriented, appears uncomfortable.
- Cardiovascular: Regular rhythm, no murmurs, rubs, or gallops. Diminished breath sounds at the bases of both lungs.
- Chest: Mild tenderness on palpation over the sternum.
- Abdomen: Soft, non-tender, non-distended.
- Extremities: No edema or cyanosis.
Assessment and Plan:
Based on the patient’s symptoms and physical exam, a working diagnosis of acute coronary syndrome is suspected. The patient will undergo further testing including an electrocardiogram (EKG) and cardiac enzyme blood tests. Aspirin and nitroglycerin will be given for symptom relief. The patient will be admitted to the hospital for further management and observation.
CPT Code: 99284 – Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history, a detailed examination, and medical decision-making of moderate complexity.
Note: This is just a sample chart and should not be used for actual medical purposes. It’s important to follow proper documentation and coding guidelines when using CPT codes.