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    Question School Physicals

    Good morning! With the start of the school year, I am starting to see a few of the school physical visits in our urgent care clinic. I am wonder how everyone codes them. If it is stated as "school physical" in the assessment and there is no additional diagnosis, I use the E/M code and Z02.0...
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    Persistant Headache after a fall

    Hi! I don't know if I should use plain old R51 (headache) or a more specific code like G44.309 (Post traumatic headache, unspecified, not intractable) This patient fell while skiing a month ago and has had a persistent h/a on the right side of his head. The dr did order a CT scan, which I...
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    Pfsh

    Good morning! What is the opinion out there on "no sick contacts" counting as a component of the PFSH? I am coding for an urgent care center and right now we are at the height of URI, Bronchitis, Sinusitis and Flu season. The dr. always puts "no sick contact" or "+ sick contact" in his HPI...
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    Generic R or L Shoulder Tendonitis Help

    Good afternoon! I do coding for an urgent care facility and a small practice. Both seem to have their dx of "R shoulder tenonitis" or "L shoulder tendonitis". It is always vague. Should I use codes from M75.8 group or just put a generic M77.9 tendonitis code? With the M77.9 there is no...
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    Please help!

    Good morning! I am wondering if you can pull a dx code from Review of Systems and Exam, without it being mentioned in the CC, HPI or PFSH. Here is the encounter: "C/O sinus congestion/pressure x 1.5 weeks, +headache. Seen by PCP and Rx ZPak, (intelligible) x 5 days with some relief. States...
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    Vertigo assessment

    Hello! I'm a new coder and I think I know the answer to my own question, but I would just like a 2nd opinion. I am coding an urgent care visit. Diagnosis is otitis media, Pharyngitis and Vertigo. He has documented enough for the OM and pharyngitis, but there is really nothing to support the...
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    Workers Comp Coding

    Good morning! I am having a problem figuring out how to code a workers comp claim. This is my first coding job and this one has me stumped. A woman cut her finger with scissors while working at a salon (Sports Clips). She had a small, simple closure laceration, under 2.5 cm. Here are the...
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