Grab your ICD-10-CM Manual…it’s time for an ICD-10 check-up!
What procedure and diagnoses would you use to code the following encounter in ICD10?
Mike is a 36-year-old patient of Dr. Brice. Mike told Dr. Brice that for the past three days he has been coughing constantly. When he takes a deep breath, slight soreness is felt in his chest. He has also been coughing up some yellow-greenish colored mucus, and has experienced two days of diarrhea. Dr. Brice checked all vital signs- there is no problem with heart, but he does hear wheezing in the right lung. From his assessment, Dr. Brice prescribes Mike with antibiotics for his acute viral bronchitis and cough. He also goes over some dietary instructions to assist with the diarrhea. The expanded visit included problem focused history, and the examination lasted 20 minutes.
Let us know what you came up with in the comments below.