Pt complaining of abdominal pain. CT scan showed a metal clip in the area of pain presumably left from prior surgery (done years ago).
Provider gives diagnosis of abdominal pain, R10.9. Below that writes "metal clip in abdominal wall" (with no code selected for that additional statement). Plan is for surgical referral.
Would you code the metal clip/foreign body in addition to abdominal pain, or just the abdominal pain?
If coding the metal clip, is S30.851, Superficial foreign body of abdominal wall, correct? ("Superficial" is throwing me, but does that refer to the abdominal wall being superficial?)
Finally, if using the S code, is this initial, subsequent, or sequela? I think initial because no indication pt has been seen for this before. Agree?
Thanks for your help!
Provider gives diagnosis of abdominal pain, R10.9. Below that writes "metal clip in abdominal wall" (with no code selected for that additional statement). Plan is for surgical referral.
Would you code the metal clip/foreign body in addition to abdominal pain, or just the abdominal pain?
If coding the metal clip, is S30.851, Superficial foreign body of abdominal wall, correct? ("Superficial" is throwing me, but does that refer to the abdominal wall being superficial?)
Finally, if using the S code, is this initial, subsequent, or sequela? I think initial because no indication pt has been seen for this before. Agree?
Thanks for your help!
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