I'm trying to figure out what the principal diagnosis would be for this outpatient clinic visit.
Subjective: A 48yo male here to follow up after thoracotomy for blood in chest. He was admitted for hemothorax on right and now patient doing well after surgery.
Exam includes this: Right chest incision clean, dry, and intact.
Assessment/Plan: Fracture of rib, 807.09, multiple ribs. Right hemothorax, status post thoracotomy. He has follow-up with cardiothoracic surgeon at (name of hospital).
Provider has chosen the diagnosis of rib fracture, but I don't see that addressed at this visit (though it was on a prior visit). (We are told to code what is monitored/assessed/treated, as documented in the SOAP note.)
I thought about using V67.09 (followup exam following surgery), but that's for surveillance only following completed treatment. I'm not sure that fits here.
Sometimes I'm told if the provider gives a diagnosis, go with it because that's his/her assessment. Other times I'm told we have to watch what they choose because it may not be the most accurate or best reflect the reason for visit/treated condition.
Help! Am I over-thinking this one, overlooking something obvious, not understanding something, etc.? How would you code this?
Thanks, as always, in advance!
Subjective: A 48yo male here to follow up after thoracotomy for blood in chest. He was admitted for hemothorax on right and now patient doing well after surgery.
Exam includes this: Right chest incision clean, dry, and intact.
Assessment/Plan: Fracture of rib, 807.09, multiple ribs. Right hemothorax, status post thoracotomy. He has follow-up with cardiothoracic surgeon at (name of hospital).
Provider has chosen the diagnosis of rib fracture, but I don't see that addressed at this visit (though it was on a prior visit). (We are told to code what is monitored/assessed/treated, as documented in the SOAP note.)
I thought about using V67.09 (followup exam following surgery), but that's for surveillance only following completed treatment. I'm not sure that fits here.
Sometimes I'm told if the provider gives a diagnosis, go with it because that's his/her assessment. Other times I'm told we have to watch what they choose because it may not be the most accurate or best reflect the reason for visit/treated condition.
Help! Am I over-thinking this one, overlooking something obvious, not understanding something, etc.? How would you code this?
Thanks, as always, in advance!
