tag60
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Pt presents with acute pain at site of inguinal hernia incision. The hernia repair was done in 09/2015. He has the pain with BMs or exertion. Exam of abdomen: Soft, nontender, nondistended. Tenderness to palpation of right inguinal hernia incision site, w/o mass appreciated. Assessment by provider: Inguinal pain, 789.09, Inguinal hernia (situation), 550.90. Plan is to refer back to outside surgeon for evaluation.
I will code postop pain, 338.18, but I'm not sure that a hernia is present (as stated by provider). I don't see it on exam or anywhere else in this short clinic note that there is a bulge, recurrent hernia, or failure of repair. I'm not sure what else to pick up here to indicate status post hernia repair, or if the abdominal pain, 789.09, is correct for secondary diagnosis. (Or is there a hernia present or assumed...but we can't make assumptions...?) Help!
Thanks in advance!
I will code postop pain, 338.18, but I'm not sure that a hernia is present (as stated by provider). I don't see it on exam or anywhere else in this short clinic note that there is a bulge, recurrent hernia, or failure of repair. I'm not sure what else to pick up here to indicate status post hernia repair, or if the abdominal pain, 789.09, is correct for secondary diagnosis. (Or is there a hernia present or assumed...but we can't make assumptions...?) Help!
Thanks in advance!