Wiki help w/ DX code for ECG!

[mass31]

Patient came in for ECG recently feeling confused has a history of left parietal cavernoma s/p resection the ECG was normal expect for where the known skull defect is...Do I code the cavernoma as the reason for the test even though the patient has had a resection? and if so what is the correct code 228.02? or should it be the confusion? confusion codes to 298.9 unspecified psychosis which will be denied by medicare...

 

[mitchellde]

Patient came in for ECG recently feeling confused has a history of left parietal cavernoma s/p resection the ECG was normal expect for where the known skull defect is...Do I code the cavernoma as the reason for the test even though the patient has had a resection? and if so what is the correct code 228.02? or should it be the confusion? confusion codes to 298.9 unspecified psychosis which will be denied by medicare...

the code you have selected 298.9 is in the category for nonorganic psychosis. I do not believe this is the diagnosis the provider intended when he arote confusion. perhaps you should look at altered mental status in the 780 category. you need a symptom code for the symptom of being confused not a psychosis diagnosis. You would not use the 228.02 code as that condidtion was excized. I would clarify with the provider that his intention was altered mental status.