Wiki Exam with no diagnosis

[apoland]

Hello,
I struggle with encounter codes when there isn't a specific diagnosis being treated. I work in a specialists office and a lot of the encounter codes seem to be preventative. Any and all direction is appreciated
1. What code(s) would you use if a patient presents with concerns about something that the provider determines isn't there. For example, pt comes in for facial asymmetry post injury, but the providers determines everything looks symetric. Would you could to injury diagnosis with 7th character D?

2. Condition no longer present: pt comes in for a ganglion cyst on wrist that is no longer present at time of exam, no pain documented.

3. We treat patients for breast reconstruction. Some of these patients are prophlyactic due to high risk either gene mutation or famility history. For the initial exams prior to surgery where they are discussing history, exam, and possible surgical options is there an encounter code that can be used as a primary diagnosis? Z15.01 is not an acceptable primary diagnosis. Z40.01 and Z42.1 would be reserved for the actual surgical procedure.

THank you in advance for assistance with any of these 3.
-Autumn

 

[LisaAlonso23]

For #1, I agree with your thought process to use the injury code with 7th character D if the patient's not receiving active treatment and is in the healing stages.

For #2, look at follow-up codes.

For #3, there are prophylactic surgery codes specific to malignant neoplasms risk.

 

[apoland]

For #1, I agree with your thought process to use the injury code with 7th character D if the patient's not receiving active treatment and is in the healing stages.

For #2, look at follow-up codes.

For #3, there are prophylactic surgery codes specific to malignant neoplasms risk.

I know this is an old thread.. I appreciate your response!

2. The follow up codes are all for completed treatment. We have seen several patients come in for their surgical date and the cyst/lesion has resolved with no current symptoms and pt advised to come back if it returns.. I'm having a hard time finding a diagnosis for the E/M visit. I have no idea why the patient would keep the appt and not cancel. Same for consults, why keep a consult if the issue is resolved.

3. My understanding the Z40 codes are specifically for the surgical encounter, not for the consult. We have had issues with Z15.01 for genetic susceptibility as a primary diagnosis. We have used Z71.89- Other counseling as the primary, but I am unsure if that's appropriate. We looked at it like we counseling the patient on options for treatment.

Any thoughts are greatly appreciated.
Thanks,
Autumn