Allergy & Immunology

MORRIS, SHALLERT & ASSOCIATES

Allergy & Immunology

975 CENTRAL AVENUE • SOMEWHERE, FL 32811 • 407-555-4321

PATIENT: BAPTISMA, CORRINE

ACCOUNT/EHR #: BAPTCO001

DATE: 09/16/18

Attending Physician: Suzanne R. Shallert, MD

This 19-year old female was brought into our office by her roommate after complaining about being short of breath and dizzy. I last saw this patient six months ago. During examination, swelling of her throat began to develop. The roommate stated that the only change she was aware of was that the patient had begun taking bee pollen capsules that she bought at the health food store off campus that morning. The patient nodded her head when I asked if she had any history of an allergy to bee stings. Epinephrine was immediately injected SC 1 mg/mL of 1:1000 q 10 minutes x 2. Ambulance was called to take her to be admitted to the hospital for IV cortisone and antihistamines to diminish air passage inflammation and support improved respiratory function.

DX: Anaphylactic shock due to bee venom

Suzanne R. Shallert, MD

SRS/pw D: 09/16/18 09:50:16 T: 09/18/18 12:55:01

Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2.

I have the primary diagnosis code (T63.441A), but I cannot figure out what else I am missing such as the procedure code.

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