prasannabanala
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ICD-10 CM coding guidelines "Sore throat"
- Thread starter prasannabanala
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prasannabanala
Contributor
- Messages
- 10
- Location
- Hyderabad, Telangana
In the above snippet shared, the patient comes in with a chief complaint of Sore throat and Headache.
ED course and medical decision making
Based on her history and exam at the time of presentation, the differential diagnosis includes, but is not limited to mononucleosis, concurrent strep pharyngitis, nonspecific viral illness.
patient is an 18 y.o.female who presents with her throat onset yesterday. Diagnosed with mono, using ibuprofen but no Tylenol. She notes no cough or other upper respiratory symptoms. Some odynophagia but no dysphagia. Pain does improve with ibuprofen. Examination demonstrates stable vital signs, appears no acute distress, ENT exam is overall benign, she does have some pharyngeal erythema although no exudates. There is no other intraoral findings and her neck is supple, no meningeal signs, she has no cellulitis in head face or neck. No submandibular fullness
Testing (laboratory studies, imaging) considered but not performed: Blood work as I do not believe this would change management; no indication to repeat strep test.
Please find the above attachments for the pdx and sdx documented.
How would we consider the condition to code the pdx in the above scenario??
B27.90-Infectious mononucleosis, unspecified without complication (as documented pdx) or B27.99 (infectious mononucleosis unspecified with complication considering sore throat as complication?
Would like to get a clarification on this code set.
Thanks and Regards,
Prasanna Kumari. B
ED course and medical decision making
Based on her history and exam at the time of presentation, the differential diagnosis includes, but is not limited to mononucleosis, concurrent strep pharyngitis, nonspecific viral illness.
patient is an 18 y.o.female who presents with her throat onset yesterday. Diagnosed with mono, using ibuprofen but no Tylenol. She notes no cough or other upper respiratory symptoms. Some odynophagia but no dysphagia. Pain does improve with ibuprofen. Examination demonstrates stable vital signs, appears no acute distress, ENT exam is overall benign, she does have some pharyngeal erythema although no exudates. There is no other intraoral findings and her neck is supple, no meningeal signs, she has no cellulitis in head face or neck. No submandibular fullness
Testing (laboratory studies, imaging) considered but not performed: Blood work as I do not believe this would change management; no indication to repeat strep test.
Please find the above attachments for the pdx and sdx documented.
How would we consider the condition to code the pdx in the above scenario??
B27.90-Infectious mononucleosis, unspecified without complication (as documented pdx) or B27.99 (infectious mononucleosis unspecified with complication considering sore throat as complication?
Would like to get a clarification on this code set.
Thanks and Regards,
Prasanna Kumari. B