Provider gives "contusion" as final diagnosis, but nothing in the record supports this. Do I use it anyway? I guess he was as much at a loss what to choose as I am! Here's the note:
S: Pt fell getting out of bathtub, fell onto arms. Didn't hit or bang her head. No LOC, no headache, no nausea/vomiting, no pain anywhere. Needs a work excuse.
O: (Goes over main systems, all WNL.) Also states: "No abrasions, no bruises, no edema."
A/P: Contusion, 924.9. Note for work given. Recommend OTC Tylenol for pain.
I wondered if V65.2, person feigning illness, would be appropriate for me to code without the provider stating that himself? I have also considered V65.8, other reasons for seeking consultation. This is the entire note; I can't find even one symptom to pick up. Or do I just give the provider what he states, despite his documentation to the contrary?
Thanks so much for any input!
S: Pt fell getting out of bathtub, fell onto arms. Didn't hit or bang her head. No LOC, no headache, no nausea/vomiting, no pain anywhere. Needs a work excuse.
O: (Goes over main systems, all WNL.) Also states: "No abrasions, no bruises, no edema."
A/P: Contusion, 924.9. Note for work given. Recommend OTC Tylenol for pain.
I wondered if V65.2, person feigning illness, would be appropriate for me to code without the provider stating that himself? I have also considered V65.8, other reasons for seeking consultation. This is the entire note; I can't find even one symptom to pick up. Or do I just give the provider what he states, despite his documentation to the contrary?
Thanks so much for any input!
