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Wiki diagnosis??

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rhotonscott

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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!!
 
Did he have any type of vision loss because of the headache? If so, you can use sudden vision loss.

If no vision loss, we have just used the V code and if it is denied the patient must pay.
 
rhotonscott@yahoo.com said:
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!!
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Use the reason for the visit (chief complaint). That was headaches? What did the headaches do? Give blurry vision? Any pain? How are the headaches? Where?
There are many types of headaches so just try to get a little specific if possible.
 
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