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 ncci_2026.1.tsv
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codes_accepted=0/8
est_reimb=$0.00
hcc_raf_total=0.000
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▸ENC-44102.md// Helena Brubaker · 58F · Office visit · est. patient · 25 min2026-04-22 · Dr. R. Adeyemi, MD
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CC: Worsening shortness of breath x 5 days, productive cough, low-grade fever 100.4F.

HPI: 58yo F with hx of moderate persistent asthma and T2DM presents with progressive dyspnea on exertion since Sunday. Reports yellow-green sputum, chest tightness relieved partially by albuterol MDI (using q3-4h). Denies hemoptysis, chest pain, leg swelling. Smoker 10 pack-yr, quit 2019.

Exam: T 100.6, HR 102, RR 22, SpO2 92% RA. Lungs: diffuse expiratory wheezes, scattered rhonchi RLL. No accessory muscle use.

Assessment:
1. Acute bronchitis with bronchospasm in patient with underlying asthma — likely viral with bacterial superinfection given sputum change.
2. Asthma exacerbation, moderate.
3. Type 2 diabetes mellitus, stable on metformin.

Plan: CXR ordered. Started azithromycin 500mg x1 then 250mg x4d. Prednisone 40mg x5d. Increase ICS to high-dose. Spirometry ordered. RTC 1 week or sooner if worsening.
J20.9icd-10conf=94%
Acute bronchitis, unspecified
// 'Acute bronchitis with bronchospasm'
meat={ M:T E:T A:T T:T }
J45.41icd-10→ hcc raf=0.328conf=91%
Moderate persistent asthma w/ acute exacerbation
// 'progressive dyspnea... wheezes'
meat={ M:T E:T A:T T:T }
E11.9icd-10→ hcc raf=0.105conf=97%
T2DM without complications
// Assessment 3, on metformin
meat={ M:T E:F A:T T:T }
Z87.891icd-10conf=78%
Personal history of nicotine dependence
// 'Smoker 10 pack-yr, quit 2019'
99214cpt$132conf=86%
Office visit, est. patient, moderate MDM (30-39 min)
// 2+ chronic stable, 1 acute w/exacerbation, prescription mgmt
94640cpt$28conf=62%
Pressurized inhalation treatment
// Albuterol MDI use noted — only bill if administered in clinic
71046cpt$64conf=78%
Radiologic exam, chest, 2 views
// 'CXR ordered' — bill if performed in office
94010cpt$38conf=71%
Spirometry
// 'Spirometry ordered'
● connectedfhir://prodUTF-8LFLn 1, Col 1 · MD

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