Wiki Pain Management Visit (Dx Coding)

[Rajesh Kumar J]

A pain mgt fw-up visit after 2 months with new lesions distally in the finger, long finger was healing. He did have an infection in it and currently taking Keflex for it, otherwise medical condition unchanged.

Provider's final assessment is:
1. Thromboangiitis obliterans (443.1)
2. Peripheral neuropathy (356.9) secondary to ischemia (459.9)

Physical exam demonstrated hyperalgesic around the index finger area.

Plan: Percocet refill p.o. b.i.d.

Suggest best diagnosis codes for this encounter.

Thanks

 

[dwaldman]

Is this an EMR note where the physician selects the condtion with associated ICD-9 displaying also. It seems that they were able to capture the condtion described in the HPI and PE and the DX listed would be sufficient unless you are looking more sign/symptom of the condition when I looked up hyperalgesic and saw hyperalgesia which said "see also distrurbance, sensation 782.0"