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Coding co-pilot
Suggest ICD-10/CPT from clinical notes with NCCI edit checks.
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ENC-44102
Helena Brubaker · 58F · Office visit · est. patient · 25 min
CC: Worsening shortness of breath x 5 days, productive cough, low-grade fever 100.4F. HPI: 58yo F with hx of moderate persistent asthma and T2DM presents with progressive dyspnea on exertion since Sunday. Reports yellow-green sputum, chest tightness relieved partially by albuterol MDI (using q3-4h). Denies hemoptysis, chest pain, leg swelling. Smoker 10 pack-yr, quit 2019. Exam: T 100.6, HR 102, RR 22, SpO2 92% RA. Lungs: diffuse expiratory wheezes, scattered rhonchi RLL. No accessory muscle use. Assessment: 1. Acute bronchitis with bronchospasm in patient with underlying asthma — likely viral with bacterial superinfection given sputum change. 2. Asthma exacerbation, moderate. 3. Type 2 diabetes mellitus, stable on metformin. Plan: CXR ordered. Started azithromycin 500mg x1 then 250mg x4d. Prednisone 40mg x5d. Increase ICS to high-dose. Spirometry ordered. RTC 1 week or sooner if worsening.
Co-pilot suggestions
0 accepted · est. $0.00 reimbursement
J20.9ICD-1094%
Acute bronchitis, unspecified
"Assessment line 1: 'Acute bronchitis with bronchospasm'"
J45.41ICD-1091%
Moderate persistent asthma with (acute) exacerbation
"Assessment 2 + HPI: 'progressive dyspnea... wheezes'"
E11.9ICD-1097%
Type 2 diabetes mellitus without complications
"Assessment 3 stable on metformin"
99214CPT86%
Office visit, est. patient, moderate MDM
"2+ chronic stable, 1 acute w/exacerbation, prescription mgmt"
94640CPT62%
Pressurized/non-pressurized inhalation treatment
"Albuterol MDI use noted — consider if administered in clinic"
71046CPT78%
Radiologic exam, chest, 2 views
"Plan: 'CXR ordered' — bill if performed in office"