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    DX code from EKG interpretation

    I am auditing some ED records and struggling if this is appropriate or not. Patients that come in with chest pain and the provider orders an EKG. There is a signed machine-generated EKG tracing in the record. It is appropriate to assign the diagnosis, such as Incomplete RBBB or abnormal ECG...
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    Ecode 917.2

    Auditing a record where pt came to the ED for a laceration to 3rd toe that he sustained while swimming in a lake and stepped on a sharp rock. I am thinking the Ecode should be E917.2, striking against or struck accidentally in running water; but I am thrown by "running water". Does anyone...
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    Dx & Mgmt Options-sleep study results

    Est pt is seen in clinic for review of sleep study results. I am having a hard time with where this would fall under Dx&Mgt Options. Est problem, stable? The patient is not presenting with anything acute, worsening, or requiring add'l workup. :confused:
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    Is the Plan same as an order

    :confused:I am auditing some clinics records and under the Plan of Care the provider indicated "Testosterone 100mg q2w". We are having a difference of opinion if this is considered the order or does there need to be a separate order form filled out. The patient has been coming every two weeks...
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    Code for healed burns

    I am auditing some records in a burn clinic and struggling with the dx code assignment for patients who come in for a recheck and their burns are healed and they are released from treatment. Since the burn is healed the acute code would not be assigned. Is a V-code appropriate? Aftercare? My...
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    DX Dilated Earlobe Piercing

    I am stumped on a diagnosis code for "dilated earlobe piercing. Patient is to RTC for repair. thanks!