Wiki Unsure of what dx code to use... please help.

[lauraruc@hotmail.com]

I'm not sure what the best code would be for a patient (5months old) that was recently seen at our Urgent Care. This is the basic provider note, does anyone have a suggestion for what to use?
Note:
parents brought patient into clinic, worried about him possible having something in his eye. They think he may have possibly rubbed some barbecue sauce in the eye but they don't know. This started about 4 hours ago.

Objective:
Alert, playfull. Doesn't appear to be in any distress at all.
HEENT: Normal. No redness, swelling or mattering. No sign of FB
NECK: Supple without nodes
LUNGS: Clear
ABDOMEN: Normal
Assessment: EYE IRRITATION

I'm not aware of any "eye irritation" codes. And I don't think there are any sign/symptoms codes I could use because there wasn't eye pain, eye redness, eye dryness or FB in eye. Would this be a worried well visit?

 

[eadun2000]

I would use 379.99. I dont think there is anything else you can use. Just my two cents.

 

[JR]

Dr. states this started 4 hrs. ago, I don't know what "this" is. You are right there is no eye irritation so I would also go with 379.99 over worried well.