Wiki Needing Help

[mlsstnt@aol.com]

I bill occupational medicine wc indiana

patient comes into out office chief complaint swallowed a staple the day before~employee drinking pop working on a bulletin board and staple must have flew into her pop she states when she took a sip she felt something in her throat she was throwing up all night when she swallows throat is irritated & she states she can feel it when she shallows~neg for pain neg for problems breathing xrays done 4 cervical no metal noted we sent patient to the ER for further treatment ER did xrays and also found nothing

What dx do i use~cant be foreign body nothing found
I'm thinking 910.8 Injury Superficial Throat Other w/out infection
Since she was complaining of irritation in her throat I dont think I can use 462 because thats for sore throat but i cant find anything under Irritation throat
Please Help thanks Melissa

 

[AForeman]

it would be appropiate to use dx 933.0 or 784.99.

 

[ohn0disaster]

Okay, since the patient came in fearing that she had swallowed a staple and nothing was found, my thoughts are that you have to go with her symptoms of throat irritation and vomitting along with the code for "Person with feared complaint in whom no diagnosis was made". Since nothing was found to be wrong, you cannot code 933.0, there was no foreign body so it is definitely NOT appropriate to use this code. Also, who said that there was an injury found in her throat? Does the doctor claim in his/her notes that no foreign body was found but the patient does have superficial injury to the throat, warranting the 910.8 code being used? She does not have a disease or disorder so you cannot use 462, or any other codes outside of the Signs and Symptoms portion of your book.

That being said, code 784.99 should be assigned as it includes "Feeling of foreign body in throat". Code 787.03 can be used for the vomitting and code V65.5 should be assigned for "Person with feared complaint in whom no diagnosis was made; feared condition not demonstrated".

Hope this helps.