In for routine OB visit and ultrasound review. In assessment/plan, provider writes:
IUP at 32 weeks, 0 days.
Right ventricle of heart measured small -- peri appt on 8/8/16
PPD positive, chest x-ray negative
Anemia. Continue iron.
My question is whether I can code the second statement above as a (suspected) abnormality, O35.8XX0, or whether the provider needs to state it as such (use the word "abnormal"). Or does small in this context mean abnormal? I would think not necessarily, but then there is mention of that upcoming appointment, looks like a followup scan to be done.
I would appreciate any input on this. Thanks in advance!
IUP at 32 weeks, 0 days.
Right ventricle of heart measured small -- peri appt on 8/8/16
PPD positive, chest x-ray negative
Anemia. Continue iron.
My question is whether I can code the second statement above as a (suspected) abnormality, O35.8XX0, or whether the provider needs to state it as such (use the word "abnormal"). Or does small in this context mean abnormal? I would think not necessarily, but then there is mention of that upcoming appointment, looks like a followup scan to be done.
I would appreciate any input on this. Thanks in advance!