What section of the CPT® - 4 manual will be used to code the attending physician’s services?

PROGRESS REPORT
LOCATION: In
-
patient Hospital
PATIENT: Donald Harris
ATTENDING PHYSICIAN: Timothy L. Pleasant, MD
The patient is doing relatively well in general. I believe the sodium of 152 that was done yesterday morning
was wrong since it has dropped down to 132 in 6 hours, which is impossible to happen.
He continues to need oxygen and he continues to be hypoxic. H
is V/Q scan showed intermediate probability,
but his ABGs were not suggestive of respiratory alkalosis.
PHYSICAL EXAMINATION: Blood pressure seems to be stable. Heart rate is 70 per minute, paced. He is
afebrile.
He has decreased air entry
bilaterally in t
he bases. I did not hear any crackles. Abdomen is negative.
Extremities show no edema.
Chest x
-
ray shows some bilateral pleural effusions, more on the right side.
Creatinine was 0.8. Basic metabolic panel was normal today with a sodium of 139.
IMPRESSION:
1.
Severe congestive heart failure
2.
Hypoxia probably related to the bilateral pleural effusions
3.
Pleural effusion
PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the
pulmonologist on call in the morning t
o check on him and see if we could do a therapeutic and diagnostic
thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary
emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural
effusions. I discussed
this with the patient.
He agrees with the plan
.
What section of the CPT
-
4 manual will be used to code the attending physician’s services?