Wiki Discomfort vs Pain

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PVAzCPC

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Ok, here's a stupid question for a Friday am:

Primary Care SOAP note documents subjective "...c/o dark, frothy urine" and "...vague complaint of left testicular discomfort."

Physical exam documents "...normal testicles, possible some varicosities on the left..."

When queried for more specifics, provider suggested I code urination discomfort/pain and testicular pain....

Neither of these are documented, unless discomfort is synonymous w/ pain (is it in the world of Coding?), then I could use testicular pain, but for the urine complaint?

Am I over-thinking this whole thing?? :confused: (BTW: OCD is my middle name!)
 
Thank you for your reply! Don't think I can use 791.9, as the "dark frothy urine" is subjective, not an actual examination of the urine (as in urinalysis).

Guess my question really is can I code "pain" from the documented "discomfort"? And can I code dysuria because the provider said to, doesn't that need to be documented in the note?
 
you are correct you cannot code dysuria just from being verbally informed. Dark Frothy urine is not automatically synonymous with dysuria. Also I agree that the 791.9 cannot be used as a finding has not been documented. it looks like the 608.9 is the only viable alternative here, however the documentation does state the testicles are normal on examination and the patient had a vague complaint of discomfort which is definitely not the same as pain. So perhaps the code for general symptoms is the best 780.99.
 
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