SienTC1720
Networker
A patient was seen in the hospital and treated with antibiotics, and then referred to our surgeon for follow up. This is the note I have:
S. Here today in follow-up of her episode of diverticulitis with either a small abscess or large diverticulum. She is currently feeling well and has no symptoms except her energy levels are down.
PE: Reveals her abdomen is soft and nontender. No masses are noted.
A. Status post episode of diverticulitis now completed antibiotics and asymptomatic.
P. I have advised the patient I would recommend following up with her regularly scheduled colonoscopy which will be next year, otherwise I would be glad to see her again if she develops problems.
My question is, what do I use for diagnosis code? Should I use Malaise/fatigue for the low energy level, or some sort of status post diverticulitis?
S. Here today in follow-up of her episode of diverticulitis with either a small abscess or large diverticulum. She is currently feeling well and has no symptoms except her energy levels are down.
PE: Reveals her abdomen is soft and nontender. No masses are noted.
A. Status post episode of diverticulitis now completed antibiotics and asymptomatic.
P. I have advised the patient I would recommend following up with her regularly scheduled colonoscopy which will be next year, otherwise I would be glad to see her again if she develops problems.
My question is, what do I use for diagnosis code? Should I use Malaise/fatigue for the low energy level, or some sort of status post diverticulitis?