C l a i m D x

CPT man­ual

I was sit­ting com­fort­ably on the couch, watch­ing the foot­ball game in the liv­ing room on a cold, win­ter Sun­day after­noon. the New York Giants were play­ing the New York Jets in a game for big apple brag­ging rights. the game was close and time was run­ning out. I gave it my undi­vided attention.Suddenly, my wife runs down the stairs and heads towards me car­ry­ing my two year old son. Fran­ti­cally, she states, “I think he’s sick. Look at him, plus he hasn’t eaten all day.” This was unusual for my son. He usu­ally eats any and every­thing avail­able. I see sweat drip­ping from his fore­head. I check for a fever by putting my hand on his fore­head and i’m sur­prised by how cold it is. “He is freez­ing,” I state.“Do some­thing,” she screams at me. I look at my son who is lay­ing in her arms, limp as can be with his eyes barely open. This is a far cry from the two year old who is nor­mally keep­ing busy by ter­ror­iz­ing every­thing and every one in the house. “You’ve got to do some­thing,” she con­tin­ues. “Isn’t this what you do for a liv­ing?” She had turned to sar­casm so I knew that she was really upset and unrav­el­ing. Our son had never been sick in the two plus years that he’d been alive.I began to take him from her. At that moment, when we were both hold­ing him, mak­ing the exchange, he began to cough. He unleashed a cough that’s only heard from vet­eran drinkers who chase the smell of alco­hol from their breath by smok­ing half a pack of cig­a­rettes a day. He con­tin­ued to cough, an uncon­trol­lable cough that led to him vom­it­ing. the pro­jec­tion was mostly in my direc­tion, but my wife caught some of the after effects. She grabbed a nearby towel and began to wipe his face. I stood him up and aimed his head away from us in case he had more to offer.

My wife looked at me once again. “What are you going to do for him? Don’t you do this for a liv­ing?” She was vis­i­bly upset and the sar­casm was at its fullest. “Don’t you take care of patients? This is a patient.” I knew that see­ing some­one ill or hurt or help­less, espe­cially if that some­one was your child, was a hard pill to swal­low, but geez…I hurt too. Finally I yelled, “I AM NOT A DOCTOR. I AM JUST A coder.” I had never referred to this posi­tion as ‘just’ a coder. I know that coders play a very impor­tant role in med­i­cine, but let’s face it, I’m no doc­tor. She looked at me and seemed to calm down. She jumped on the phone and began speak­ing with his pediatrician’s office. While she did that, I did what comes naturally…I began to code.

I put my hands on my son’s neck then on his fore­head. This time he was burn­ing up. He had a fever. I sat down and cra­dled him in my arms. He was shak­ing. Although he was hot, he was expe­ri­enc­ing chills.

I leafed through the alpha­betic pages of my men­tal ICD-9-CM man­ual and found the codes for chills with fever, cough and vom­it­ing. I was sure to con­firm them in the numeric index. My wife hung up the phone and explained that we were going to take him to the pediatrician’s office. they had told her to bring him in right away.

We quickly changed clothes, grabbed our coats and headed for the front door. I attempted to use my periph­eral vision to steal a glance at the tele­vi­sion in hopes of catch­ing an update on the score of the game, but my wife pressed the power but­ton on the remote before I could.

We arrived at the office and were called in imme­di­ately. My son’s doc­tor asked, “what’s wrong with him?” My wife’s voice echoed loudly in my head, ‘DO SOMETHING.’ So I did. I handed my son to the doc­tor and con­fi­dently stated, “he is expe­ri­enc­ing a 780.6, has a 786.2 and 787.03 all over my wife and I. He is all your now.” the doc­tor laughed, my wife smiled and I was back on her good side. 

ICD 9 CM

After an estab­lished, office visit E&M code, my son turned out to have 382.9, Oti­tis media. Doc gave him antibi­otics and a cough sup­pres­sant and sent us on our way.

R. Rus­sell, CPC