Here’s a sample coded report for CPT code 99282, which corresponds to an initial hospital care visit for a moderately severe condition:
Patient Encounter
Patient: John Smith, a 47-year-old male
Date of Encounter: April 13, 2023
Location of Encounter: General Hospital
Chief Complaint
The patient presents to the hospital with complaints of severe chest pain that started this morning while he was at work. He describes the pain as a squeezing sensation in the center of his chest that radiates to his left arm.
History of Present Illness
The patient reports no prior history of chest pain or heart disease. He denies any shortness of breath, nausea, vomiting, or diaphoresis. He states that he has been under a lot of stress at work lately and has not been eating as well as he should.
Past Medical History
The patient reports a history of hypertension, for which he takes lisinopril. He denies any other chronic medical conditions.
Medications
- Lisinopril 10mg PO daily
- Acetaminophen 650mg PO PRN for pain
Physical Examination
The patient appears uncomfortable but is able to speak in full sentences. Vital signs are as follows: blood pressure 160/90 mmHg, heart rate 110 bpm, respiratory rate 18 bpm, oxygen saturation 98% on room air.
Cardiovascular: Regular rhythm, tachycardic, no murmurs, rubs or gallops noted.
Respiratory: Clear to auscultation bilaterally.
Gastrointestinal: Soft, non-tender abdomen, bowel sounds present.
Neurological: Alert and oriented, no focal deficits.
Assessment and Plan
Based on the patient’s symptoms and physical examination, the initial diagnosis is acute coronary syndrome. The patient will be admitted to the hospital for further evaluation and management. The plan includes:
- CBC, BMP, troponin levels, ECG, and a chest X-ray to be ordered
- Administration of aspirin 325mg chewed, nitroglycerin SL 0.4mg, and heparin IV bolus per protocol
- Consultation with cardiology for further management
- Pain management with acetaminophen as needed
- Patient to remain NPO until further notice.
CPT Code
99282 – Initial hospital care for a moderately severe condition.