Question

Sing the following progress note, define the bolded terms within the chart provided This patient is being treated with their primary care physician after visiting the urgent care this weekend. Progress Note: Patient is a 45 y.o. female who presents to rule out unstable diabetes. She initially made a visit to the urgent care one day prior with complaints of excessive thirst, increased urination, and fatigue. Her fasting blood sugar was 350. She was treated and referred to this practice for a consult. History: Patient has a history of polycystic ovarian syndrome, congenital hypothyroidism, benign thyroid nodule, and early menopause. Assessment: Patient's Accu-Check is currently 400. Her vital signs like symptoms with complaints of nausea and fatigue along with increased urination and excessive thirst are stable. She continues to have flu- Plan: Direct admission to South Hospital, 24-hour urine test, repeat Accu-Check, thyroid function, cortisol blood test stat. Refer to Dr. Jones, endocrinologist for consult today Impression: Hyperglycemia (abnormal glucose) Jill Smith DNP Do not forget to include the sources for your definitions.

Answer 1

Part 2:

Hyperglycemia unspecified

ICD-10-CM code: R73.9

Justification:

The patient is not diagnosed related to increased blood sugar level. The laboratory test of her fasting blood sugar shows elevated blood sugar level. The cause is unidentified. So the patient has to be coded for hyperglycemia unspecified R73.9

Hypothyroidism (congenital Iodine deficiency syndrome unspecified)

ICD-10-CM code: E00.9

Justification:

The patient has a history of Congenital hypothyroidism. Hypothyroidism is a condition where the thyroid gland is unable to produce enough hormones. Iodine is essential for the normal function of the thyroid gland and production of hormones. The deficiency in iodine results in the deficiency of thyroid hormones which occur as a congenital disorder for this patient. So the code E00.9 says congenital iodine deficiency syndrome unspecified.

Source: AAPC coder.