Help with dx code for resolved symptoms

maryek28@outlook.com

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Anchorage, AK
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The patient was seen for a sore throat and painful swallowing but the documentation says that the symptoms had resolved. This is the first time the patient is being seen for this problem, but it is an established patient. Z09 seems inappropriate since this is not a follow up visit for the problem. What code should be used here?
 

thomas7331

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If the documentation supports that those symptoms are the reason for the visit and are what is being evaluated, then it is still appropriate to code them even if they are not actively having the symptoms at the time of the encounter. Patients often have symptoms intermittently that require evaluation - for example, a patient may experience palpitations and need to be evaluated by a cardiologist or require a Holter monitor even if they aren't having those symptoms at the time they are at the physician's office.
 
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