Respiratory system



Respiratory system



The respiratory system often reflects diseases in other organ systems of the body. The process of respiration includes not only the lungs but also the diaphragm, the brain (regulates respiration through cerebral regulatory centers), and the cardiovascular system. The physician treating the patient with pulmonary disease must take into consideration a wide variety of pathological considerations. For example, areas of density on a chest x-ray may be caused by pulmonary infection or tumor. Dysfunction of the lungs could represent a systemic disease, such as an embolism or a cardiac disturbance. The physician will begin the diagnostic process with a complete history and physical.



E/M services


During the history portion of the service, the physician will be seeking information about factors that would have an effect on the patient’s lungs, such as exposure to tobacco smoke, pollution, asbestos, coal, and other irritating respiratory factors. A family history of lung disease, such as asthma, allergies, lung cancer, or chronic obstructive lung disease, is significant for making a diagnosis. The personal history includes eliciting information about previous lung infections, such as tuberculosis or pneumonia, and other factors that have an effect on the respiratory system, such as drug abuse or human immunodeficiency virus (HIV). The patient’s history of medications is important, as some drugs can affect long-term lung function.


The physical examination will reveal much to the skilled clinician. For example, if there is an absence of breath sounds during inspiration over a certain area of the lung, the absence may indicate atelectasis (incomplete expansion of the lung) or a pleural effusion (liquid in the pleural space). Tenderness over the sinus area may indicate a sinus infection, or clubbed fingers may indicate lung cancer or cystic fibrosis. Each element in the physical examination is important in the diagnostic process and is noted in the medical documentation.



From the Trenchesimage


“Become active in your local Chapter. Learn everything you can in coding even if it doesn’t apply to the job you have today.”


KATHY


Common respiratory symptoms are chronic cough, sore throat, and hemoptysis (blood in sputum). Conditions of the respiratory system frequently include upper respiratory infection, laryngitis, croup, bronchiolitis, asthma, bronchitis, chronic obstructive pulmonary disease, pneumonia, atelectasis, and pulmonary embolus. Common procedures include endotracheal intubation, tracheostomy, thoracentesis, biopsies, and various endoscopic procedures, such as sinus endoscopy or bronchoscopy. Pulmonary specialty studies include pulmonary function, oxygen saturation, polysomnogram, and sleep studies. X-rays and computerized tomography (CT) scans are often part of the medical documentation for patients with respiratory conditions.


Physicians who specialize in treatment of the nose and throat are otolaryngologists, and physicians who specialize in treatment of the respiratory system are pulmonologists.



Enzyme immunoassay


An EIA (enzyme immunoassay) is screening for strep. Streptococcus organisms are classified by means of the Lancefield classification into Groups A through O. The CPT manual divides Streptococcus into Groups A and B. Group A is Streptococcus pyogenes, which can be a cause of sore throat (pharyngitis). A culture allows identification of the cause of the pharyngitis. The patient presents to the laboratory, and laboratory personnel will swab the pharyngeal wall and tonsillar area. The material on the swab is placed into a medium (culture medium) that allows for the growth of the microorganism over a period of time. Newer methods allow results to be known more quickly; these are termed rapid detection methods and are not cultured (noncultured). Noncultured is also known as primary source, which means that instead of waiting for the overnight incubation, as is required in the cultured method, the swabbed material is incubated with an acid solution or an enzyme that extracts the Group A antigen. EIA that utilizes this fast test method is manufactured in a kit, much like the commercially available pregnancy test kits that are now readily available. A plus sign appears to indicate that Streptococcus was detected, and a minus sign appears to indicate that no Streptococcus was found in the sample. These results are stated on a laboratory report that is sent to the physician for review.


The diagnosis for the laboratory tests is not stated in the laboratory report; rather, when the service is submitted for reimbursement, the reason for the service is stated as the diagnosis assigned by the physician. Laboratory results are not used for diagnosis unless a physician has interpreted the results.


You can locate the various enzyme immunoassays in the index of the CPT manual under Antigen Detection.



CASE 9-1   9-1A Evening Clinic, Sore Throat9-1B Laboratory, Respiratory Cultures


CASE 9-1



9-1A  Evening clinic, sore throat


LOCATION: Outpatient, Clinic


PATIENT: Cindy Byer


PHYSICIAN: Ronald Green, MD


This established patient presents to the evening clinic on May 9. She relates that she has had a sore throat for 1 day. No fever. No nausea, vomiting, or diarrhea. No significant runny nose or congestion. She has had occasional nonproductive cough, which she attributes to smoking.


EXAMINATION: The patient is an alert, cooperative, 36-year-old white female with a temperature of 99.6˚ F. AU (both ears) TMs (tympanic membranes) are clear. The nose is inflamed but patent. Sinuses are nontender. The oropharynx is hyperemic. The are no exudates. There is a bit of food debris in the right tonsillar crypt. Neck is supple without significant nodes. Lungs are clear to auscultation. A 4-hour EIA (enzyme immunoassay) strep screen is pending.


ASSESSMENT:



PLAN: An EIA strep screen is pending. We will call her back with the results but will have her call back if she has not heard from us by 11 o’clock tomorrow morning. Hygiene precautions are discussed, and over-the-counter medication is also discussed. Further treatment pending the results of the strep screen.





Residents


As a part of the medical resident’s education, each resident is required to serve a rotation in a variety of health care settings under the direct supervision of a qualified physician who serves as the resident’s supervisor and teacher. When the health care services provided by the resident are not directly reported to all the third-party payers (e.g., Medicare), the HCPCS modifier -GC (performed in part by a resident) or -GE (performed completely by a resident) is sometimes used on the code submitted for the teaching physician to indicate that the resident, under supervision of the teaching physician, performed a portion of the service and that the resident’s notes have been considered when reporting the teaching physician’s service. For example, in the following case, the teaching physician dictated a history and physical on admitting a patient to the hospital. The resident also dictated a history and physical. The coder uses both the teaching physician’s notes and the resident’s notes to report the teaching physician’s services of a hospital admission.


Most third-party payers will not reimburse a facility for services performed completely by a resident.



CASE 9-2   9-2A Admission History and Physical (Physician’s and Resident’s Notes)9-2B Radiology Report, Chest9-2C Radiology Report, Chest9-2D Thoracic Medicine/Critical Care Progress Report9-2E Thoracic Medicine/Critical Care Progress Report9-2F Thoracic Medicine/Critical Care Progress Note9-2G Discharge Summary


CASE 9-2


Dr. Dawson admitted Mr. Gulman to the hospital and prepared an admission history and physical. Dr. Grovedahl is a resident being supervised by Dr. Dawson. When completing the audit form for the admission service, place a “image” on the form to indicate elements Dr. Dawson provided and an “×” to indicate elements Dr. Grovedahl provided. Dr. Grovedahl performed only part of the service because Dr. Dawson also contributed to the service. Assume that the third-party payer requires the use of the HCPCS modifiers for those services provided in part by a resident.



9-2A  Admission history and physical (physician’s and resident’s notes)


LOCATION: Inpatient, Hospital


PATIENT: Ervin Gulman


PRIMARY CARE PHYSICIAN: Ronald Green, MD


ATTENDING PHYSICIAN: Gregory Dawson, MD


PHYSICIAN ADMISSION NOTES: The emergency room notified that the patient presented himself there with increasing shortness of breath, and of course he had an abnormal chest x-ray. This is the same patient I tried to talk into coming into the emergency room earlier, and Dr. Green also tried even a week before that, and he has now agreed that perhaps he is sick enough to come in.


He is a patient who is well known to me, so a lot of history is already in the clinic chart. His past medical history, social history, family history, and review of systems are outlined in detail by my resident. Please see the resident’s note for complete details of the entrance history and physical.


The patient has significant COPD (chronic obstructive pulmonary disease) with hypoxic, hypercarbic respiratory failure on today’s blood gases. He has had diminished appetite for a couple of weeks and dry mouth, and he is too short of breath really to eat well. He is on home O2 (report dependence on supplemental oxygen with a V code), and he has been on Avalax since the 10th. Before that he had a week’s worth of antibiotics as well, but I do not know what they were. No fevers, sweats, or chills were present. He had increasing malaise, and he had some fever, with a temperature of 101° F to 102° F before admission.


The time I saw the patient revealed a very ill-appearing white male. HEENT (head, ears, eyes, nose, throat) is benign. No blood in the nose or posterior pharynx. The neck is supple without adenopathy. No JVD (jugular vein distention). Thyroid is not palpably enlarged. Lungs have diminished air movement everywhere, with rales in the right. No wheezes, rhonchi, or rubs. Heart shows a heart rate of about 110. I thought it was regular, without an S3 (third heart sound) or S4 (fourth heart sound). No diastolic sounds, clicks, or rubs; maybe a grade 1 murmur over the fourth intercostal, but his heart is so fast I am not sure what exactly I am hearing at this point. Abdomen is benign without hepatosplenomegaly. Normal bowel sounds are present. No bruits are heard in either flank. No masses are palpable, nontender, somewhat distended and tympanitis but within the range of normal. Neurologically he is awake and alert. Extremities show no edema, rashes, clubbing, cyanosis, or tremor except some ecchymosis in his upper arms, probably from steroid use. Neurologic: Cranial nerves II-XII are intact, and there is symmetrical strength in all four extremities. A detailed exam is not done because of his respiratory distress. Lymphatics: There are no nodes in the neck, clavicular, or axillary area.


IMPRESSION:




Resident’s admission notes


LOCATION: Inpatient, Hospital


PATIENT: Ervin Gulman


PRIMARY CARE PHYSICIAN: Ronald Green, MD


ATTENDING PHYSICIAN: Gregory Dawson, MD


RESIDENT: Mandy Grovedahl, MD


CHIEF COMPLAINT: Increasing shortness of breath and malaise


HISTORY OF PRESENT ILLNESS: This 73-year-old male was seen in Dr. Green’s office 1 week ago to follow up on pneumonia. The patient had been taking quinolone for a week for a pneumonia that had been diagnosed approximately 2 weeks previously when he had presented with cough, fever, chills, and shortness of breath. Since then, those symptoms have resolved. The patient complained of a decreased appetite at home and complaining of a dry mouth. He is on home O2 and has been on Avelox since the 10th when he went to the office to see Dr. Green. Over the past 2 days he has complained of increasing shortness of breath, increasing malaise, temperature 101° F to 102° F yesterday. He denies any nausea, vomiting, or diarrhea.


PAST MEDICAL HISTORY:



MEDICATIONS:



ALLERGIES: Aspirin


PAST SURGICAL HISTORY: Right jaw repair following a broken jaw. No other surgeries.


FAMILY HISTORY: Father passed away at age 86 of congestive heart failure. Mother passed away at age 78 of colon cancer. The patient has three brothers and one sister alive. Two brothers have pacemakers. One sister has COPD.


SOCIAL HISTORY: Patient one pack daily × 45-year smoker. He quit approximately 15 years ago. He does have a history of heavy drinking in the past but denies any current use. He currently lives in Manytown with his wife.


REVIEW OF SYSTEMS: Constitutional: The patient indicates that there was an 18-pound weight loss approximately 2 months ago secondary to some fluid overload. He denies any headaches. He has had a decreased appetite in the past week or so, and he sleeps well with no problems. Eyes: Denies any history of glaucoma and has no eye pain or blurry or double vision. Ears, nose, mouth, and throat: No hearing problems reported. No bleeding from the nose or mouth. Cardiovascular: Denies palpitations. Denies any pressure or racing heartbeat. He does complain of some substernal chest pain off and on with exertion, last experienced approximately 1 week ago. Respiratory: Chronic cough, which is productive of white sputum. Dyspnea on exertion. GI (gastrointestinal): No history of ulcers. No digestive problems. He has had some positive stools recently. GU (genitourinary): History of prostate problems. Positive burning with urination recently. Skin: Complaint of dryness around the nares. No rashes. No nonhealing lesions. Musculoskeletal: No arthritis. No complaints of joint pain. No loss of muscle strength. Psych: Patient does have a history of anxiety secondary to shortness of breath. Neuro: No epilepsy or history of seizures. Hematology: Patient states he bruises easily. He does not have a bleeding problem. Endocrine: No kidney problems. No thyroid problems.


PHYSICAL EXAMINATION: Vitals: Pulse 105. Blood pressure 132/157. O2 saturation on 3L nasal cannula is 82% to 89%. Respirations are mid 20s to 30s. Temperature 36.8° C. HEENT: Normocephalic and atraumatic. Extraocular movements are intact. Neck is soft. No cervical adenopathy. Pharynx is without erythema. There are no oral lesions. Cardiovascular: Tachycardia. No murmurs, rubs, or gallops heard. Respiratory: Diminished air movement in bilateral bases. Minimal respiratory wheeze heard. No rhonchi or rales appreciated. Abdomen: Soft, positive bowel sounds, nondistended. The patient complains of positive tenderness to palpation over the right upper quadrant. Musculoskeletal: Strength is 5/5 and equal bilaterally upper and lower extremities. Extremities: No clubbing, cyanosis, or edema. Full range of motion times four. Neuro: Cranial nerves II-XII grossly intact. Sensation is intact.


LABORATORY: Sodium 142, potassium 4.4, chloride 96, CO2 greater than or equal to 41.8, BUN (blood urea nitrogen) 17, creatinine 0.7, and glucose 129. Calcium 8.9. White blood cells 9.7, hemoglobin 15.6, and platelets 202. ABGs (arterial blood gases) from this morning: pH (potential of hydrogen) 7.439, pCO2 (partial pressure of carbon dioxide) 52.9, pO2 (oxygen pressure) 55.2, bicarbonate 35.1, O2 saturation 94% on 3L nasal cannula from 9:30 this morning, when he came in through the emergency department. Chest x-ray from 2 weeks ago revealed extensive opacities on the right side, awaiting results of x-ray from the emergency room this morning. I will review those this afternoon with Dr. Dawson.


ASSESSMENT/PLAN: Pneumonia right-sided in someone with COPD. Patient is oxygen dependent due to chronic respiratory failure. He has been placed on Claforan, Zithromax, and Solu-Medrol as well as a variety of breathing treatments. We will monitor labs, ABGs, and x-ray. See orders for remainder.




9-2B  Radiology report, chest


This radiology report indicates that there were two parts to the chest film (upper and lower); however, this is a single view (anteroposterior, front to back). It is the number of views that is reported.


LOCATION: Inpatient, Hospital


PATIENT: Ervin Gulman


PRIMARY CARE PHYSICIAN: Ronald Green, MD


ATTENDING PHYSICIAN: Gregory Dawson, MD


RADIOLOGIST: Morton Monson, MD


EXAMINATION OF: Chest


CLINICAL SYMPTOMS: Pneumonia, COPD (chronic obstructive pulmonary disease), and chronic respiratory failure


PORTABLE CHEST: SINGLE VIEW: FINDINGS: Study is compared today with the study dated 2 weeks ago. Cardiac monitor leads overlie the patient. This chest film is obtained in two parts—one contains the upper portion of the chest, the second the lower portion of the chest. Cardiac silhouette is prominent but stable. Pulmonary vasculature also mildly prominent but stable. The left lung appears relatively clear. There is some linear opacity, left infrahilar area, consistent with segmental volume loss. Opacity is seen in the right lung with some mild sparing of the right apex. This is a mixed interstitial and alveolar pattern with a more focal area of opacity in the right mid-lung extending to the lateral chest wall. Pleural density is seen along the right lateral chest wall, and there is an unusual lucency over the right heart border. Osseous structures are stable.


IMPRESSION:





9-2C  Radiology report, chest


Dr. Monson suggested further imaging, and based on that recommendation, Dr. Dawson ordered a posteroanterior (PA) and lateral chest x-ray.


LOCATION: Inpatient, Hospital


PATIENT: Ervin Gulman


PRIMARY CARE PHYSICIAN: Ronald Green, MD


ATTENDING PHYSICIAN: Gregory Dawson, MD


EXAMINATION OF: Chest


CLINICAL SYMPTOMS: Pneumonia, COPD (chronic obstructive pulmonary disease), and chronic respiratory failure


PA (POSTERIOR/ANTERIOR) AND LATERAL CHEST X-RAY, 9:15 AM: Previous portable upright only yesterday


CLINICAL INFORMATION: There is cardiomegaly, as there has been on previous x-rays for this patient. The vascular markings on the left are within normal limits. On the left, there is what appears to be interstitial fibrosis, mid-lung and base. No left effusion suggested. On the right, there is abnormal density throughout the right lung that is interstitial in nature and could be unilateral failure pattern. That is less confluent than it was in the right upper lobe compared with the previous report. The remainder of the right lung (mid-lung and base) shows no change from previous report. There is blunting of the right costophrenic angle and the right posterior sulcus suggesting a small effusion that is stable. There is some pleural density along the right lateral chest wall and over the apex that is assumed to be scarring. There is degenerative change of the thoracic spine, mild. No destructive lesion or fracture is seen.


IMPRESSION:





9-2D  Thoracic medicine/critical care progress report


Note that the physician changed the diagnosis from “pneumonia” to “pneumonia, interstitial-type,” which is in the inner spaces of the lung linings. Since the outpatient coder reports only those diagnosis(es) stated on that current report being coded, the diagnoses for this patient will need to reflect this more current diagnosis.


LOCATION: Inpatient, Hospital


PATIENT: Ervin Gulman


PRIMARY CARE PHYSICIAN: Ronald Green, MD


ATTENDING PHYSICIAN: Gregory Dawson, MD


The patient has a right-lung pneumonia, interstitial-type; COPD (chronic obstructive pulmonary disease) and chronic respiratory failure. Yesterday’s x-ray showed maybe some clearing. The sputum culture so far is not very helpful. The Gram stain does show evidence of gram-positive disease with moderate gram-positive cocci and moderate gram-positive cocci in clusters. He is taking Claforan and Zithromax, which should cover that. He seems to be responding and is a little more energetic.


OBJECTIVE: He has been afebrile since he has been here. HEENT (head, ears, eyes, nose, throat): Benign. Neck: Supple without JVD (jugular vein distention). Chest: Symmetrical. Rales on the right. Very distant breath sounds. Left sounds pretty good. I do not hear any rales, anyway, but again, distant breath sounds. Heart: S1 (first heart sound) and S2 (second heart sound) are regular with a grade 1/6 murmur at the fourth interspace near the sternum that really does not radiate much. Abdomen: soft. Benign without hepatosplenomegaly. Extremities: No clubbing. No edema.


The patient is a significant CO2 (carbon dioxide) retainer but does not really tolerate BiPAP much at all, and he tried that in the past. He seems to be quite claustrophobic and just cannot do it. I will put him back on his BuSpar, put him back on his Lasix today 40 mg (milligram) a day, and we will continue the rest of the drugs. We will start physical therapy with him a little bit to see if we cannot get him moving. His Solu-Medrol is every 6; go down to every 8 today. I would like to discharge him after a good 5 days of antibiotics, as I am sure the x-ray is better.




9-2E  Thoracic medicine/critical care progress report


LOCATION: Inpatient, Hospital


PATIENT: Ervin Gulman


PRIMARY CARE PHYSICIAN: Ronald Green, MD


ATTENDING PHYSICIAN: Gregory Dawson, MD


The patient has significant COPD (chronic obstructive pulmonary disease), is oxygen dependent, and has chronic respiratory failure. He had an extensive right-lung pneumonia, interstitial type, basically sparing the apex. Gram stain showing gram-positive cocci in the chains and clusters. No pathogen was grown. He is actually doing better. He was able to walk in the hallway a little bit.


EXAMINATION: He has fewer rales. He still has a little bit of wheeze. His weight, however, has gone up. He has some edema in his legs. We will have to give him some Lasix today. I am sure this is fluid retention from steroids. He weighs about 3 pounds more now than he did on the 27th (186 pounds).


The plan is to finish out this week with steroids. I will taper him off so he will be done on the 2nd. With any luck, he can be discharged on the 3rd. Recheck a chest x-ray tomorrow. Recheck his oxygen level. He gets a little dizzy when he stands up, and that may be from hypercarbia, which he is prone to have. Hopefully things are improving enough that we can get him home on Friday.




9-2F  Thoracic medicine/critical care progress note


On this report the physician indicates that the interstitial is now clear, so the diagnosis for the pneumonia is no longer the interstitial type.


LOCATION: Inpatient, Hospital


PATIENT: Ervin Gulman


PRIMARY CARE PHYSICIAN: Ronald Green, MD


ATTENDING PHYSICIAN: Gregory Dawson, MD


The patient is here for pneumonia that is clearing on x-ray. Interstitially clear. On exam, it is clearing. He is symptomatically better and is afebrile. On exam, he still has a few rales at the base. Very distant breath sounds, but he has extremely severe COPD (chronic obstructive pulmonary disease). His O2 (oxygen) requirement is back down to his usual 2 L (liter). His pO2 (oxygen pressure) 60, pCO2 (partial pressure of carbon dioxide) 77, pH (potential of hydrogen) 7.38, and that is his usual set of blood gases. He still has a little edema on exam. Heart shows a regular flow as well as a regular rhythm.


DISPOSITION: We will switch from IV (intravenous) antibiotics to oral antibiotics. If he is doing this well tomorrow, I can discharge him at that time, and with any luck we can get him discharged tomorrow and home.




9-2G  Discharge summary


LOCATION: Inpatient, Hospital


PATIENT: Ervin Gulman


PRIMARY CARE PHYSICIAN: Ronald Green, MD


ATTENDING PHYSICIAN: Gregory Dawson, MD


The patient was admitted with pneumonia, increasing shortness of breath, and failure to thrive. He had been treated as an outpatient for similar things but has gradually declined and become quite fatigued and increasingly short of breath. He had acute pneumonia, unknown organism, at the time of admission. I do not think our cultures helped much in identifying a causative organism. His case was gradual slow improvement. He was able to take care of himself a little bit, and he was able to be discharged.


The Gram stain suggested a streptococcal or even a streptococcal organism with moderate gram-positive cocci in pairs and gram-negative cocci in clusters, but no cultures actually revealed pathogenic diagnosis.


We finally were able to discharge him today to his home under the care of his family.


MEDICATIONS: he was discharged with were:



The Vantin will be discontinued on the 5th after his dose on that day. Follow-up will be in a week in the office to repeat his chest x-ray. His O2 (oxygen) was set at 4 L (liter) with 2 L continuously.


DISCHARGE DIAGNOSES:





CASE 9-3   9-3A Thoracic Medicine/Critical Care Consultation9-3B Thoracic Medicine/Critical Care Progress Note9-3C Radiology Report, Chest9-3D Thoracic Medicine/Critical Care Progress Note9-3E Thoracic Medicine/Critical Care Progress Note9-3F Radiology Report, Chest9-3G Discharge Summary


CASE 9-3


Dr. Dawson was called to the emergency department for a consultation regarding Kurt Troy, who presented with pulmonary edema and respiratory failure. During the consultation, Dr. Dawson decided to admit Mr. Troy to the hospital. The consultation then becomes a hospital admission and is reported as an admission, not as a consultation, even though you will note that the report is titled a consultation. Dr. Dawson admitted the patient and is the attending physician. The ventilation services are bundled into the E/M codes and are not to be reported separately. This patient has a myriad of problems; when reporting the diagnoses, report the chief reason(s) the patient reported for this service. In Case 9-3, you will find the diagnoses highlighted for you to illustrate how the diagnosis changes slightly from report to report.


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May 17, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Respiratory system

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