symptoms

  1. A

    Wiki Coding symptoms of TIA

    I have coders and auditors suddenly coding symptoms of TIA such as slurred speech, facial droop, parenthesis, etc. My understanding and coding practice has always been that only the code for TIA would be used as this is not coded the same way CVA is. Thoughts??
  2. U

    Wiki Urinary tract infection and Symptoms - Nausea/Vomiting

    Hi All, Can anyone here let me know whether we can code nausea and vomiting along with Urinary tract infection(Unspecified). ICD-10 CM guidelines states signs and symptoms cannot be coded with integral part of disease condition. Is it applicable to unspecified urinary tract infection? Where...
  3. L

    Wiki Uti - If a patient has urinary

    If a patient has urinary symptoms, Doc does dip stick. Rx antibiotic. Culture pending. Provider documents UTI and codes : N39.0 no bacteria identified Is this coded as signs and symptoms until culture results?
  4. J

    Wiki PEG tube eval

    My doctor has seen a patiet in the hospital for PEG tube eval, the report states that the patient is at high risk for aspiration. It does not mention dysphagia or any other symptoms, I am not sure what code to use for this. Please Help!
  5. A

    Wiki Colonoscopy coding - When coding for the physician

    When coding for the physician preforming the colonoscopy, is it ok to just code the colonoscopy from only the op note and not look back at the H & P or Pre op notes? I have heard some other coders are doing this. The reason I ask is that a Dr. may mention symptoms (rectal bleeding possible from...
  6. N

    Wiki "Extended post-viral bronchial hyperresponsiveness"

    I need help. The patient does not have Asthma and I cannot locate anything that resembles this diagnosis! Can any help me? Would the provider code the symptoms only since it's "post"???
  7. E

    Wiki TB

    My NP saw a pt that is being asked by her new employer for a TB test. The patient is 9 weeks postpartum and breastfeeding and can't have a TB test. We saw her to verify she does not show any symptoms of TB and she has never had a positive TB test. Not sure on what dx to use. I'm going between...
  8. C

    Wiki Meniscal tear

    The patient is a 66-year old male who had sustained an injury to his right knee when he stepped into a hole on the sand on the beach. This resulted in significant and persistent billow-sided joint pain. While he had a history of previous knee problems, he had not had this level of symptoms...
  9. ljones88

    Wiki Modifying factors determinaton

    Hi all, Our physician documented an HPI that I pasted directly below. My question is this: Would the statement "Symptoms are not improved by humidified air, sitting up and cough drops," count towards a modifying factor? "History of Present Illness Cough: XXX presents with complaints of...
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