andrewsdiane@comcast.net
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In order to code a fever or count it in the HPI as severity and in the MDM does it have to be over 100.5? Thank you
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Wiki Fever
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MnTwins29
True Blue
I don't see anything in ICD-9/10 guidelines or the AHA Coding Clinic that state the temperature has to be documented at 38 degrees C (100.4 degrees F) in order to code this - the ICD definition in both systems states fever is a body temerpature that is higher than normal. So, no I don't believe the patient's temperature has to be documented as such in order to assign the Dx code or use fever in MDM.
Think about this for a minute - patient's temp is 99.8, physician documents a slight fever, recommends patient take Tylenol in the treatment plan. Wouldn't you count the fever then as it was part of the MDM and per coding guidelines, it can be coded?
Think about this for a minute - patient's temp is 99.8, physician documents a slight fever, recommends patient take Tylenol in the treatment plan. Wouldn't you count the fever then as it was part of the MDM and per coding guidelines, it can be coded?
BenCrocker
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I run at about 99 degrees normally so it's not always best to code it. That's just me though. I know 98.6 is an average but I'm sure there's an acceptable range for "normal".
At the end of the day we are coders, not clinicians. If the doctor's diagnosis is fever, who am I to say different? They went to med school, saw the patient, and applied their best clinical judgement to come to that conclusion. It is our job to code the records as they have documented it, not to apply our lmiited (at best) clinical knowledge.
MnTwins29
True Blue
Agree - that is why I checked the coding guidelines first. If that specific requirement is not spelled out there, we should assign the code based on the physician documentation, not some figure listed in a clinical definition.