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Wiki Coding Headache with Tonsillitis

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meanne717

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Hi I need your input, I am currently coding ED charts. I encountered a physician documentation of headache (784.0) and tonsillitis (463) as final diagnoses. My initial thought was to code both but then I checked mayo clinic and merck manual online. Both include headache as a common symptom of tonsillitis.

Should I just code tonsillitis (463)?

Thank you
 
meanne717 said:
Hi I need your input, I am currently coding ED charts. I encountered a physician documentation of headache (784.0) and tonsillitis (463) as final diagnoses. My initial thought was to code both but then I checked mayo clinic and merck manual online. Both include headache as a common symptom of tonsillitis.

Should I just code tonsillitis (463)?

Thank you
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That will depend on the documentation. While a headache may be a symptom of tonsillitis it is also a symptom of many other things. So did the provider treat both as independent conditions, or did he link the headache to the tonsillitis and treat only the one as a means of treating both conditions. The documentation needs to be clear enough that you can tell.
 
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