Help!! Lymphadenopathy Not!

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I am at a complete loss on this one. I'm leaning towards a no charge for the fact that I have no definitive dx and/or no sign or symptom to code. Any suggestions would be great.

cervical lymphadenopathy. Patient also reports right anterior cervical lymph node. She reports she noticed it about 6 months ago. No pain to palpation of over. She denies any change in its size.

Physical Exam

Head:
normocephalic and atraumatic.
Mouth:
Pharynx unremarkable.
Neck:
No palpable lymphadenopathy.

Assessment and Plan:

Cervical lymphadenopathy (ICD-785.6) (ICD10-R59.0)
PLAN: We will check labs and do head and neck US for further evaluation of this.
 

Pam Brooks

True Blue
Local Chapter Officer
NAB Member
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Dover Seacoast New Hampshire
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I'm going to assume that the provider's lack of noting any symptomology within the examination is an EHR default, although he may not have palpated any cervical lump. It's not your call as a coder to question the clinical relevance, but from a CDI perspective, you can certainly point it out for further information.

In the assessment, the provider states cervical lymphadenopathy. Although you can reason that the patient doesn't appear by exam to have lymphadenopathy, the fact that the provider says so is reason enough to code it. See the conventions in ICD-10-CM; A.19. If the provider documents the condition...it exists. He is doing an US, so diagnostic imaging is planned.
 
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