Wheezing and respiratory distress.
My initial assessment would focus on evaluating the severity of the child\\\\\\\’s wheezing and respiratory distress. This includes observing his breathing rate, use of accessory muscles, oxygen saturation levels, and listening to his lung sounds for wheezes or decreased breath sounds. I would also assess his overall appearance, level of activity, and hydration status. Given his history of asthma and recent upper respiratory infection, I would consider the possibility of an asthma exacerbation potentially triggered by the recent upper respiratory infection.
A diagnostic procedure that can assist with the diagnosis is a pulse oxymetry to evaluate the oxygen saturation and a spirometry test to assess the lung function and confirm the severity of asthma exacerbation (Acute Asthma Exacerbation in Children, 2024). The appropriate CPT code for spirometry is 94010 (CPT Code Lookup, 2024).
Since the home albuterol and nebulizer treatments have not been effective, the patient should first receive oxygen therapy. This should be followed by corticosteroid treatment and nebulizer therapy with a mixture of short-acting beta-agonists (SABAs) and ipratropium bromide. Given the patient’s young age (3 years old) and the potential difficulty with swallowing oral medication, intravenous (IV) administration of medications can be considered. If the patient does not respond to these treatments, they should be routed to the nearest emergency room. In the emergency room setting, the patient may require IV magnesium, EKG monitoring, and possibly assistive ventilation (Acute Asthma Exacerbation in Children, 2024).
Educate the mother on proper use of the nebulizer, the importance of adherence to the asthma action plan, and recognizing signs of worsening asthma. Provide guidance on environmental control measures to reduce exposure to asthma triggers. Encourage good hand hygiene and annual flu vaccinations to prevent respiratory infections (Acute Asthma Exacerbation in Children, 2024).
Top 3 Differential Diagnoses:
Asthma Exacerbation (ICD-10: J45.901): The child\\\\\\\’s history of mild intermittent asthma and current symptoms of wheezing and respiratory distress suggest an asthma exacerbation(Acute Asthma Exacerbation in Children, 2024).
Acute Bronchiolitis (ICD-10: J21.9): The recent upper respiratory infection symptoms, such as cough, congestion, and runny nose, along with wheezing, could indicate acute bronchiolitis, especially in a young child (Bronchiolitis in Children, 2024).
Pneumonia (ICD-10: J18.9): The presence of a low-grade fever, cough, and increased respiratory effort raises the possibility of pneumonia, which can be confirmed or ruled out with a chest X-ray (Community Acquired Pneumonia in Children, 2024).
The appropriate billing code for this visit, which includes the evaluation and management of a new or established pediatric patient with these symptoms, is CPT code 99214 (CPT Code Lookup, 2024).
?References
Acute asthma exacerbation in children. (2024, February 14). Dynamed. https://www.dynamed.com/condition/acute-asthma-exacerbation-in-children
Bronchiolitis in children. (2024, April 17). Dynamed. https://www.dynamed.com/condition/bronchiolitis-in-children
Community acquired pneumonia in children. (2024, May 15). Dynamed. https://www.dynamed.com/condition/community-acquired-pneumonia-in-children
CPT code lookup. (2024). Codify by AAPC. https://www.aapc.com/codes/code-search/
Garzon, D. L., Driessnack, M., Dirks, M., Duderstadt, K. G., & Gaylord, N. M. (2024). Burns\\\\\\\’ pediatric primary care (8th ed.). Elsevier Health Sciences (US).
The Web\\\\\\\’s Free 2024 ICD-10-CM/PCS medical coding reference. (2024). ICD 10 Data. https://www.icd10data.com/
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