CHF Case Study Patient Data Anthropometrics Diet Height: 5'6" Weight: 152 lbs at doctor's office, 158 lbs on day of admission, 158 lbs today (152 lbs UBW) Mr. Nick O'Time DOB: 05/01/1950 New Mexico State University Dietetic Internship Labs Meds Intake Low Sodium Sodium, serum: 110 -Furosemide 25-50% of tray mmol/L (Lasix) 1,300-1,700 mL Osmolality, serum: -Prilosec per day 250 mOsm/Kg H2O A-Assessment 7/24 Reason for Nutrition Assessment: MR NICK O' TIME WAS REFERRED TO THE RD FROM THE PCP: SOB, EDEMA Client History (CH) note which diagnosis is the primary or admitting diagnosis CH-2.1.1 CH-1.1.1 CH-1.1.3 CH-114 CH-1.1.6 Patient chief nutrition complaint: LACK OF APPETITE/SOB/WEAKNESS Age: 69 Sex MALE Race: CAUCASIAN Language: ENGLISH Patient/Client/Family Medical/Health History: CH-2.1.1 CH-2.1.2 CH-2.1.2 Social History: CH-3.1.2 Patient chief nutrition complaint: LACK OF APPETITE/SOB/WEAKNESS Cardiovascular: CHF (PRIMARY) Cardopvascular: PYROSIS Living/housing situation (specify): LIVES ALONE Social and medical support (specify) PT DOES COOKING/SOMETIMES NEIGHBOR WILL BRING FOOD/SOMETIMES WILL GO OUT TO EAT WITH FRIENDS/SON Geographic location of home (specify): LAS CRUCES Anthropometric Measurements (AD): CH-3.1.4 CH-3.1.5 AD-1117 AD-1.1.2.1 AD-1.1.25 Usual stated body weight (UBW): 69 KG (152#) AD-1.1.5.1 Stated Height: 168 CM (5'6") Measured Weight: 71.8 KG (158#) BMI: 24.5, NORMAL (FROM UBW) Nutrition Focused Physical Findings (PD): PD-1.1.5 PD-1.15.9 PD-1.16.2 PD-1.1.18 Digestive system: PT LACK OF APPETITE >1 WEEK Constipation: PT C/O CONSTIPATION FOR THE LAST FEW DAYS +1 pitting edema: TO LEGS Teeth PT STATES MISSING TEETH BUT ABLE TO CHEW AND SWALLOW FOOD Vital signs PD-1.1.21.1 PD-1.1.21.2 Blood pressure, systolic 150 mmHg Blood pressure, diastolic: 92 mmHg Food/Nutrition Related History (FH) FH-1.2.1.1 FH-1.2.2.1 FH-1.2.2.2 FH-1.2.2.3 Oral fluid estimated intake in 24 hours: 1300-1700 ML FLUID/DAY Estimated amount of food: 25-50% OF TRAY Types of food/meals. PRE-SELECT MENU Meal/snack pattern: 3 MEALS/1 AFTERNOON SNACK PER DAY AT HOME, BUT NO SNACKS AND 3 SMALLER MEALS/DAY FOR THE PAST WEEK FH-2112 Modified diet order: LOW SODIUM DIET 13-46/DAY) ON 05/02

CHF Case Study Patient Data Anthropometrics Diet Height: 5'6" Weight: 152 lbs at doctor's office, 158 lbs on day of admission, 158 lbs today (152 lbs UBW) Mr. Nick O'Time DOB: 05/01/1950 New Mexico State University Dietetic Internship Labs Meds Intake Low Sodium Sodium, serum: 110 -Furosemide 25-50% of tray mmol/L (Lasix) 1,300-1,700 mL Osmolality, serum: -Prilosec per day 250 mOsm/Kg H2O A-Assessment 7/24 Reason for Nutrition Assessment: MR NICK O' TIME WAS REFERRED TO THE RD FROM THE PCP: SOB, EDEMA Client History (CH) note which diagnosis is the primary or admitting diagnosis CH-2.1.1 CH-1.1.1 CH-1.1.3 CH-114 CH-1.1.6 Patient chief nutrition complaint: LACK OF APPETITE/SOB/WEAKNESS Age: 69 Sex MALE Race: CAUCASIAN Language: ENGLISH Patient/Client/Family Medical/Health History: CH-2.1.1 CH-2.1.2 CH-2.1.2 Social History: CH-3.1.2 Patient chief nutrition complaint: LACK OF APPETITE/SOB/WEAKNESS Cardiovascular: CHF (PRIMARY) Cardopvascular: PYROSIS Living/housing situation (specify): LIVES ALONE Social and medical support (specify) PT DOES COOKING/SOMETIMES NEIGHBOR WILL BRING FOOD/SOMETIMES WILL GO OUT TO EAT WITH FRIENDS/SON Geographic location of home (specify): LAS CRUCES Anthropometric Measurements (AD): CH-3.1.4 CH-3.1.5 AD-1117 AD-1.1.2.1 AD-1.1.25 Usual stated body weight (UBW): 69 KG (152#) AD-1.1.5.1 Stated Height: 168 CM (5'6") Measured Weight: 71.8 KG (158#) BMI: 24.5, NORMAL (FROM UBW) Nutrition Focused Physical Findings (PD): PD-1.1.5 PD-1.15.9 PD-1.16.2 PD-1.1.18 Digestive system: PT LACK OF APPETITE >1 WEEK Constipation: PT C/O CONSTIPATION FOR THE LAST FEW DAYS +1 pitting edema: TO LEGS Teeth PT STATES MISSING TEETH BUT ABLE TO CHEW AND SWALLOW FOOD Vital signs PD-1.1.21.1 PD-1.1.21.2 Blood pressure, systolic 150 mmHg Blood pressure, diastolic: 92 mmHg Food/Nutrition Related History (FH) FH-1.2.1.1 FH-1.2.2.1 FH-1.2.2.2 FH-1.2.2.3 Oral fluid estimated intake in 24 hours: 1300-1700 ML FLUID/DAY Estimated amount of food: 25-50% OF TRAY Types of food/meals. PRE-SELECT MENU Meal/snack pattern: 3 MEALS/1 AFTERNOON SNACK PER DAY AT HOME, BUT NO SNACKS AND 3 SMALLER MEALS/DAY FOR THE PAST WEEK FH-2112 Modified diet order: LOW SODIUM DIET 13-46/DAY) ON 05/02

Understanding Health Insurance: A Guide to Billing and Reimbursement

14th Edition

ISBN:9781337679480

Author:GREEN

Publisher:GREEN

Chapter7: Cpt Coding

Section: Chapter Questions

Problem 42R

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