Wiki R68.89 possible malaria

[bellefried]

I have an ED provider with a patient presenting with a very high fever. Patient had recent travel to South America. Provider did many tests trying to track down the cause, not positive for any parasite, Covid or mosquito born illnesses. Patient was admitted Provider pre-coded the chart with Fever and R68.89 with the note suspected Malaria. Patient was admitted and treatment includes malaria drugs.

Can I code R68.89 - Other general symptoms and signs for the suspected Malaria?

 

[thomas7331]

Without reading the documentation, it's hard to answer. But R68.89 would be assigned to report a symptom that doesn't have a more specific code available. If the only symptom the provider has documented is the fever, then that's what you'd code, not R68.89. If the provider has specifically documented a suspected exposure to malaria, you may code Z20.818 - Contact with and (suspected) exposure to other bacterial communicable diseases.

 

[bellefried]

Thank you!