Subjects: challenge coding cumulative
This patient was diagnosed with a seizure disorder
A diagnosis which is determined during this encounter and requires further investigation to determine the cause
New problem (to examiner) no additional work up planned
Established problem (to examiner) stable or improved
A diagnosis which is already known to the physician and is worse since the last examination.
To code for the infusion of the normal saline and potassium turn to the
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Secondary Diagnoses codes (Index to Diseases)
1. Infusion Therapy (96365-96368, 96379
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A diagnosis which is already known to the physician and is stable or improved since the last examination.
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DIAGNOSIS: Seizure disorder, hypokalemia, hyponatremia. (Insufficient potassium and sodium)
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A diagnosis which is determined during this encounter and does not require any further investigation.
Runs a definite and prescribed course, is transient in nature and is not likely to permanently alter health status, or has a good prognosis with management/compliance.
New problem (to examiner) additional work up planned
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The code listed is 276.8; hypopotassemia. This patient was also diagnosed with hyponatremia. To locate this code, turn in the Index to Diseases to the main term hyponatremia. The code listed is 276.1; hyposmolality and/or hyponatremia.
Established problem (to examiner) worsening
Seizure, Disorder, intractable or nonintractable. 345.90 or 1
CPT Index to the main term hydration; this lists codes 96360-96361. The code for the first hour is 96360; intravenous infusion, hydration; initial, 31 minutes to 1 hour.
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The infusion took 3 hours so the code 96361; intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure), needs to be reported twice for the additional two hours of infusion.
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