I'm not sure I agree with the provider's chosen codes/assessment for this case. Here's the information:
Pt is 19 yo female, G1P1, who is complaining that "my C-section scar from 2 years ago is hurting." States that the scar has been painful and swollen for the past one month. Pain is sharp, intermittent, non-radiating and superficial to the abdominal wall. No redness or discharge from the area.
Exam of abdomen: Positive bowel sounds. Soft and mildly tender to palpation over C-section scar, lower abdomen. Scar is w/o erythema, edema, discharge. No underlying mass. No guarding, no HSM.
Provider's Assessment:
Abdominal wall pain, 789.09
Previous C-section, 654.20
Plan: Obtain ultrasound of abdominal wall to r/o any underlying pathology. Consider adhesions vs suture that hasn't dissolved vs other pathology.
I'm thinking to code the scar condition, perhaps 709.2? I don't see true abdominal pain for the chosen 789.09 -- it's scar pain in the area of the abdomen, which is different, right? And aren't 600 codes only for pregnancy, childbirth, puerperium?
I hate to keep claiming inexperience, but I'm a new coder and just wanting to make sure I'm not making any wrong assumptions. Sometimes I'm told if that's what the provider states, then use it. Other times I'm told they're often in a rush and pick the first code that looks close enough, and we need to fine tune...
Thanks in advance for your help!
Pt is 19 yo female, G1P1, who is complaining that "my C-section scar from 2 years ago is hurting." States that the scar has been painful and swollen for the past one month. Pain is sharp, intermittent, non-radiating and superficial to the abdominal wall. No redness or discharge from the area.
Exam of abdomen: Positive bowel sounds. Soft and mildly tender to palpation over C-section scar, lower abdomen. Scar is w/o erythema, edema, discharge. No underlying mass. No guarding, no HSM.
Provider's Assessment:
Abdominal wall pain, 789.09
Previous C-section, 654.20
Plan: Obtain ultrasound of abdominal wall to r/o any underlying pathology. Consider adhesions vs suture that hasn't dissolved vs other pathology.
I'm thinking to code the scar condition, perhaps 709.2? I don't see true abdominal pain for the chosen 789.09 -- it's scar pain in the area of the abdomen, which is different, right? And aren't 600 codes only for pregnancy, childbirth, puerperium?
I hate to keep claiming inexperience, but I'm a new coder and just wanting to make sure I'm not making any wrong assumptions. Sometimes I'm told if that's what the provider states, then use it. Other times I'm told they're often in a rush and pick the first code that looks close enough, and we need to fine tune...
Thanks in advance for your help!
