Bernadette10
Guru
This patient had a reaction to Aciphex before she was seen for this office visit, and medication adjustment was previously made. Should this be coded as R11.2, R51.9 and T47.1X5D, Z87.898 history of other specified conditions, Z78.9 other specified health status, or something else? I'm leaning toward Z87.898 but wonder what other people think.
Had reaction to Aciphex (n/v, headache, emotional lability, neuralgia, muscskel pain). She is now taking Omeprazole 40 mg BID and is asymptomatic.
IMPRESSION:
K22.70-530.85 Barrett's esophagus. The difference between erosive esophagitis and Barrett's esophagus explained to Joanne and she verbalized understanding. She declines offer of printed material; states she will look it up online.
K21.9-530.81 GERD (gastroesophageal reflux disease): Dec 2022 EGD showed LA grade D erosive esophagitis. Nov 2023 EGD showed resolved esophagitis and long segment Barrett's esophagus.
T47.1X5D Adverse effect of proton pump inhibitor (Aciphex; severe: N/V, headache.)
PLAN:
---Decrease omeprazole from 40 mg bid to qd
---Repeat EGD in 3 yrs
---F/U with me PRN.
Had reaction to Aciphex (n/v, headache, emotional lability, neuralgia, muscskel pain). She is now taking Omeprazole 40 mg BID and is asymptomatic.
IMPRESSION:
K22.70-530.85 Barrett's esophagus. The difference between erosive esophagitis and Barrett's esophagus explained to Joanne and she verbalized understanding. She declines offer of printed material; states she will look it up online.
K21.9-530.81 GERD (gastroesophageal reflux disease): Dec 2022 EGD showed LA grade D erosive esophagitis. Nov 2023 EGD showed resolved esophagitis and long segment Barrett's esophagus.
T47.1X5D Adverse effect of proton pump inhibitor (Aciphex; severe: N/V, headache.)
PLAN:
---Decrease omeprazole from 40 mg bid to qd
---Repeat EGD in 3 yrs
---F/U with me PRN.