Diagnosis clarification


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Shouldn't the provider document their final diagnosis? we aren't to assume?

63-year-old gravida 2 para 2 was seen several weeks ago with inflamed cervix repeat Pap smear showed no evidence of any dysplasia other than the fact that she had lymphocytic cervicitis. Exam today there was no contact bleeding but there is there was a circumferential superficial erosion colposcopy was performed showed no evidence of any mosaicism punctation or abnormal vasculature to suggest a premalignant condition however I have advised the patient that freezing a cryocautery will be beneficial.

She also has a moderate cystocele and the uterus is fairly well supported so I discussed the issue with the patient and she is completely asymptomatic and the dependent portion of the cystocele is still within the vaginal introitus so I urged the patient not to do engage in heavy lifting and she has no symptoms no urgency no stress incontinence so I will not recommend surgery at this time.

She will return for cervical freezing at her convenience.
Hi Kobee:)
The provider is telling you in the documentation the patient's problem ....inflamed lymphocytic cervicitis. In the ICD10manual it refers you to dx N72 and add B95-B97 once the lab results tell you the exact bacteria. Add dx N81.10 for unspecified cystocele in the vaginal wall /tunnel of opening or introitus. At times the provider will list the final assesments and sometimes you have to read it out/abstract it out of the provide current documentation for the treatment type. I have abstracted coded both ways. If still confused query your provider.
Well I hope helped you today.:)
Lady T