apoland
Networker
Hello,
I struggle with encounter codes when there isn't a specific diagnosis being treated. I work in a specialists office and a lot of the encounter codes seem to be preventative. Any and all direction is appreciated
1. What code(s) would you use if a patient presents with concerns about something that the provider determines isn't there. For example, pt comes in for facial asymmetry post injury, but the providers determines everything looks symetric. Would you could to injury diagnosis with 7th character D?
2. Condition no longer present: pt comes in for a ganglion cyst on wrist that is no longer present at time of exam, no pain documented.
3. We treat patients for breast reconstruction. Some of these patients are prophlyactic due to high risk either gene mutation or famility history. For the initial exams prior to surgery where they are discussing history, exam, and possible surgical options is there an encounter code that can be used as a primary diagnosis? Z15.01 is not an acceptable primary diagnosis. Z40.01 and Z42.1 would be reserved for the actual surgical procedure.
THank you in advance for assistance with any of these 3.
-Autumn
I struggle with encounter codes when there isn't a specific diagnosis being treated. I work in a specialists office and a lot of the encounter codes seem to be preventative. Any and all direction is appreciated
1. What code(s) would you use if a patient presents with concerns about something that the provider determines isn't there. For example, pt comes in for facial asymmetry post injury, but the providers determines everything looks symetric. Would you could to injury diagnosis with 7th character D?
2. Condition no longer present: pt comes in for a ganglion cyst on wrist that is no longer present at time of exam, no pain documented.
3. We treat patients for breast reconstruction. Some of these patients are prophlyactic due to high risk either gene mutation or famility history. For the initial exams prior to surgery where they are discussing history, exam, and possible surgical options is there an encounter code that can be used as a primary diagnosis? Z15.01 is not an acceptable primary diagnosis. Z40.01 and Z42.1 would be reserved for the actual surgical procedure.
THank you in advance for assistance with any of these 3.
-Autumn