Wiki Which diagnosis code would you use?

[KEVANS5102]

Chief Complaint:

60 year old male Pt states slept in CL's 10 days ago, when woke in the AM had blood on pillowcase and blood in nasal corner of OD. Unsure where blood was coming from. Notes maybe some discomfort w/CL's. Notes blood on pillowcase for next 4 days. Has since resolved, but notes some crusts yesterday AM, no blood. No change w/vision OU.

MD chooses this as a diagnosis:

366.12 (incipient cataracts) Patient is currently asymptomatic and functioning well. Monitor.

 

[cjhalk@yahoo.com]

Boy - That is odd.

I certainly would not use the 366.12 - Incipient Cataract.

First off, I would recommend the provider go back and document something else.

But I think this would be a good time to use 799.9 - unknown and unspecified cause of morbidity/mortality.

Documentation doesn't seem to be a big help. Patient slept in contact lenses, but had blood on the pillow as well as his/her nose. The blood isn't tied into the sleeping in the contact lenses or that there is an actual problem with the patient's eyes.

I think at best, the nose is documented over the eyes. But since we are talking both nose and eyes, the provider doesn't specifically note where the crust is forming - eyes or nose.

But overall, I don't see anything that warrants an actual problem. The blood was never according to the notes confirmed was coming from the nose or the eyes. Nothing was done about "cataract." Nor was this address as a problem.

So, I think according to documentation, there isn't a code you can use except 799.9.

 

[KEVANS5102]

Thank you for your insight!