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Wiki Auditing subsequent care visit

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graciejean

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A patient with a newly diagnosed stroke is seen by the neurologist in follow up. A detailed exam is performed. For MDM notes:
R hemispheric infarct
repeat CT head R (illegible word) infarct with hemorrhagic (illegible word)
will check MRI head tomorrow to determine extent of stroke/hematoma
will hold antithrombolytics for now
will follow.

The overall risk I can see is high, but the established diagnosis of rt hemispheric infarct would be 2 points for est problem worsening due to hemorrhagic... MDM would only meet low 99231.
Is there a possibility that the hemorrhage would be the second problem for another 2 points to make this high MDM?
 
Help-diagnosis code

In this scenario would there be one diagnosis of 434.91 for the Rt hemispheric infarct? or would there a second diagnosis code for rt hemispheric infarct with hemorrhagic (illegible word)?
 
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