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cperez

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Hello all,
I do E/M coding and have come across a problem. Recently with the H1N1 flu we have had patients who come in becuase their job or daycare needs a note stating they are not sick. In the case of the note I am having problems with the cc is "Day care needs clearance for child due to flu season."
HPI reads:
Illness-Fever-Flu
Reported by parent.
Onset/Timing: NO fever, or signs of the flu
Context: no ill contacts; no recent travel; no new medications
Associated Symptoms: no rash; no lethargy; Daycare needs to have excuse
An ROS and physical exam was performed.
Since the patient has no signs and symptoms of an illness should I bill an E/M with diagnosis V65.5 or should I code a physical and use diagnosis V70.3.
Please help!!!!!!!!!!!!!!!!1
 
To me, it looks like the parent IS reporting a subjective complaint of a febrile illness, either current or recent.

"Illness-Fever-Flu
Reported by parent."

Maybe they kept the child out for a day or two and now, in light of the current scare with H1N1, the daycare is requesting the docs statement clearing them to go back. What I don't see in your note is the assesment and plan. It appears the child has no obvious physical findings related to illness at present, but any parent can tell you that a child can run fever and still be running around playing. (especially in the doctor's office waiting room !!)

I would look at the rest of the note for the A/P. If I had to choose from the two V codes suggested, I would probably go with the first rather than the second. On the other hand, if the parent truly was reporting fever, then I would probably code it as such since that appears to actually be the CC.
 
Hi Barbara,
Thanks for your response. That illness-fever-flu is part of the template the clinician selected. It is not actually what the patient, or parent in this case, stated. I spoke to the clinican who saw the patient and she informed me the patient had not been sick in the past couple of weeks or present. The day care just wanted her examined without any signs or symptoms.
 
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