rhotonscott
Networker
A young patient comes to the ophthalmologist. He was sent by school because of headaches after reading. The doctor does an intermediate eye exam (everything but dilated fundus exam). His exam notes are: 20/25 both eyes. His assessment is: Healthy. His plan is: follow up with PCP. Since the doctor had to do the workup can I code the diagnosis as : 784.0 (headache NOS)? The guidelines say I can use signs&symptoms if no definitive diagnosis, but this pt is healthy. Do I have to go with a low level E/M code and use the V72.0 (examination of eyes and vision)? I can see using V codes if it was a patient with no symptoms coming in for a routine examination, but this young patient has symptoms of possible eye-related problems... Imput, Please!!