pedscoder21
Guru
How do you code the final diagnosis in this scenario?
Patient had orchiopexy in August. Has a hematoma at the site. Mother wants site checked.
Assessment and plan:
Hematoma of groin, sequela
The physician has coded S30.1XXS (contusion of abdomen, sequela). From what I understand about sequela, this is incorrect because that would mean that there is a late effect of the hematoma - please correct me if I'm wrong!
It seems to me that the physician is wanting to code the fact that the hematoma is a result of the procedure (which is NOT stated in the record, I will have to query). I believe that code would be: I97.62 - postprocedural hemorrhage and hematoma of a circulatory system organ or structure following other procedure. Again, correct me if I'm wrong!
Appreciate any feedback
Patient had orchiopexy in August. Has a hematoma at the site. Mother wants site checked.
Assessment and plan:
Hematoma of groin, sequela
The physician has coded S30.1XXS (contusion of abdomen, sequela). From what I understand about sequela, this is incorrect because that would mean that there is a late effect of the hematoma - please correct me if I'm wrong!
It seems to me that the physician is wanting to code the fact that the hematoma is a result of the procedure (which is NOT stated in the record, I will have to query). I believe that code would be: I97.62 - postprocedural hemorrhage and hematoma of a circulatory system organ or structure following other procedure. Again, correct me if I'm wrong!
Appreciate any feedback