After reviewing below scenario, how would you code and sequence the diagnoses? - Would you code the symptoms first and then the hydrocephalus (headache-R51, nausea-R11.0, hydrocephalus-Q03.9)? Or instead of coding the hydrocephalus, code the presence of the CSF shunt (R51, R11.0, Z98.2)?
Assessment: Pt has a history of congenital shunted hydrocephalus (has Strata valve set at 1.0 in place, connected to bilateral frontal caths, last revised 2 years ago), presenting with headache and nausea. Subtle increase in the size of the left lateral ventricle. Shunt system appears to be intact on shunt series.
-Imaging reviewed
-Pt appears to be feeling better on repeat exam
-Will admit for observation overnight
-Please obtain CBC, BMP, coags
-NPO after midnight
-Pain control w/ Tylenol
Any feedback is greatly appreciated.
Thanks!
Assessment: Pt has a history of congenital shunted hydrocephalus (has Strata valve set at 1.0 in place, connected to bilateral frontal caths, last revised 2 years ago), presenting with headache and nausea. Subtle increase in the size of the left lateral ventricle. Shunt system appears to be intact on shunt series.
-Imaging reviewed
-Pt appears to be feeling better on repeat exam
-Will admit for observation overnight
-Please obtain CBC, BMP, coags
-NPO after midnight
-Pain control w/ Tylenol
Any feedback is greatly appreciated.
Thanks!
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