This pt comes in complaining of a hernia. Provider gives that diagnosis under assessment BUT then puts a question mark and orders ultrasound for further workup. I know we don't code suspected conditions for outpatients, but I'm not sure I can find any symptoms to code or if the documentation supports hernia and I'm okay to use that. Here's the verbatim note:
S: Male with complaint of hernia. States has two masses that are painful to palpation on his left side in inguinal area.
O: Abdomen: Soft, NT, ND. There are palpable soft (firm?) areas along the femoral area that suggest either small fat hernia in femoral vs inguinal. On cough, I don't appreciate inguinal ring weakness.
A/P: Hernia ? check/confirm any contents on US. I suspect this will be watchful waiting.
I considered an observation code (Z03.89, encounter for observation of other suspected diseases and conditions ruled out)--but has the hernia been ruled out?
If hernia, where? Or use K46.9, unspecified? (But then provider typed in that question mark as above!)
Or what is a symptom or definite finding I could code instead of hernia?
Any guidance appreciated! Thanks so much to all for the help I get on this board.
S: Male with complaint of hernia. States has two masses that are painful to palpation on his left side in inguinal area.
O: Abdomen: Soft, NT, ND. There are palpable soft (firm?) areas along the femoral area that suggest either small fat hernia in femoral vs inguinal. On cough, I don't appreciate inguinal ring weakness.
A/P: Hernia ? check/confirm any contents on US. I suspect this will be watchful waiting.
I considered an observation code (Z03.89, encounter for observation of other suspected diseases and conditions ruled out)--but has the hernia been ruled out?
If hernia, where? Or use K46.9, unspecified? (But then provider typed in that question mark as above!)
Or what is a symptom or definite finding I could code instead of hernia?
Any guidance appreciated! Thanks so much to all for the help I get on this board.
