Pt was washing his BBQ grill with an alkaline solution and some of it splashed into his eye. He rinsed his eye out with water and presented to clinic after it continued to be red and his vision became blurry.
Eye exam (key points): Heavily injected, copious clear tearing, pupil reactive.
(No mention of abrasion at all; no mention of cornea per se. Yet see below.)
Diagnosis: "Corneal abrasion, 918.1, due to alkaline chemical burn."
Is it okay for me to use 940.2? Should I also include the corneal abrasion--THOUGH eye exam does not even state that?
This is where I become uncertain about how much leeway I have as a coder. I'm told our providers use SNOMED, type in key term/diagnosis, find the closest code, and choose that. Sometimes they don't make the best choices or don't realize a different key term to use (I guess).
What would you use as the primary diagnosis?
Thank you!! And thanks for putting up with my multiple questions today.
Eye exam (key points): Heavily injected, copious clear tearing, pupil reactive.
(No mention of abrasion at all; no mention of cornea per se. Yet see below.)
Diagnosis: "Corneal abrasion, 918.1, due to alkaline chemical burn."
Is it okay for me to use 940.2? Should I also include the corneal abrasion--THOUGH eye exam does not even state that?
This is where I become uncertain about how much leeway I have as a coder. I'm told our providers use SNOMED, type in key term/diagnosis, find the closest code, and choose that. Sometimes they don't make the best choices or don't realize a different key term to use (I guess).
What would you use as the primary diagnosis?
Thank you!! And thanks for putting up with my multiple questions today.
