Pathos
True Blue
Perhaps I am overthinking this scenario, but I could use some feedback on this one:
Provider sees patient as follow up from a recent Urgent Care visit. Symptoms from the UC visit has now completely been resolved, but wants to talk about depression and anxiety. She is being followed by another provider, not part of this Clinic, and is having a tough time getting seen by this other provider. She is having pharmaceutical side effects from taking her meds (brain fog, forgetful). When she does forget her meds, which is frequent, she gets "electric jolts". She also has her ears feeling plugged.
Provider doesn't find anything in the patient's ears; spends some some discussing medication. States to continue one med; titrating down another med, and writes out a prescription for it, and the patient can be seen by this provider if the patient can't be seen by her BH provider (in 4-6 weeks).
Codes out Dx: Z86.59 Personal history of other mental and behavioral disorders
Here's the rub:
1) Is Z86.59 billable as a single diagnosis code for what is described above?
2) Since the primary reason for this visit was unremarkable, the provider might be looking for something else to code out. I was thinking "R57.9 - Shock, unspecified" for the electric jolts the patient is experiencing.
3) Can't bill out "Unspecified disorder of ear, unspecified ear. H93.90" since the clinical examination was benign.
Thoughts, comments?
Thanks!
Provider sees patient as follow up from a recent Urgent Care visit. Symptoms from the UC visit has now completely been resolved, but wants to talk about depression and anxiety. She is being followed by another provider, not part of this Clinic, and is having a tough time getting seen by this other provider. She is having pharmaceutical side effects from taking her meds (brain fog, forgetful). When she does forget her meds, which is frequent, she gets "electric jolts". She also has her ears feeling plugged.
Provider doesn't find anything in the patient's ears; spends some some discussing medication. States to continue one med; titrating down another med, and writes out a prescription for it, and the patient can be seen by this provider if the patient can't be seen by her BH provider (in 4-6 weeks).
Codes out Dx: Z86.59 Personal history of other mental and behavioral disorders
Here's the rub:
1) Is Z86.59 billable as a single diagnosis code for what is described above?
2) Since the primary reason for this visit was unremarkable, the provider might be looking for something else to code out. I was thinking "R57.9 - Shock, unspecified" for the electric jolts the patient is experiencing.
3) Can't bill out "Unspecified disorder of ear, unspecified ear. H93.90" since the clinical examination was benign.
Thoughts, comments?
Thanks!