maudys
Networker
Patient presents with rectal bleeding, with documentation as follows:
O: Rectal exam finds one largeexternal hemorrhoid without blood present. No anal fissures are appreciated. Rectal tone is normal. Very possibly has internal hemorrhoids but no pain on palpation. Rectal vault is empty of stool. No masses are appreciated. A very small amount of light brown stool is present and is heme-positive.
A: Rectal bleeding, history of diverticulosis.
P: Empiric treatment for diverticulosis with metronidazole 500 mg t.i.d. for 7 days and Septra DS b.i.d. for 7 days. We would like her to take Metamucil a half dose twice a day. Push fluids and increase fiber rich foods on her diet. Monitor temperature.
Because the patient was treated empirically for the diverticulosis, would you code the encounter as rectal bleeding (569.3) and diverticulosis (562.10), or rectal bleeding (569.3) and history of digestive disorder (V12.79?)
O: Rectal exam finds one largeexternal hemorrhoid without blood present. No anal fissures are appreciated. Rectal tone is normal. Very possibly has internal hemorrhoids but no pain on palpation. Rectal vault is empty of stool. No masses are appreciated. A very small amount of light brown stool is present and is heme-positive.
A: Rectal bleeding, history of diverticulosis.
P: Empiric treatment for diverticulosis with metronidazole 500 mg t.i.d. for 7 days and Septra DS b.i.d. for 7 days. We would like her to take Metamucil a half dose twice a day. Push fluids and increase fiber rich foods on her diet. Monitor temperature.
Because the patient was treated empirically for the diverticulosis, would you code the encounter as rectal bleeding (569.3) and diverticulosis (562.10), or rectal bleeding (569.3) and history of digestive disorder (V12.79?)