als695
Contributor
Good morning!
I am wondering if you can pull a dx code from Review of Systems and Exam, without it being mentioned in the CC, HPI or PFSH. Here is the encounter:
"C/O sinus congestion/pressure x 1.5 weeks, +headache. Seen by PCP and Rx ZPak, (intelligible) x 5 days with some relief. States getting worse again".
Then he does the ROS and mentions things that support acute sinusitis/allergic rhinitis.
In the ROS, he also mentions L shoulder pain. In the exam he lists the details of examining the L shoulder.
My question is, is it enough that he mentions it in the ROS and Exam that I can code for a shoulder strain, as he has listed it as a diagnosis. Also, there is no mention of how/why he has this shoulder strain. It is just stated in the exam section that the patient encountered shoulder stress x 5 days ago.
This is for an urgent care clinic and it is not computerized. The doc is old school and much of his documentation is so hard to read and (IMO) the encounter forms are not very good. Can't wait until they go electronic!
Thank you in advance!
Amy S.
I am wondering if you can pull a dx code from Review of Systems and Exam, without it being mentioned in the CC, HPI or PFSH. Here is the encounter:
"C/O sinus congestion/pressure x 1.5 weeks, +headache. Seen by PCP and Rx ZPak, (intelligible) x 5 days with some relief. States getting worse again".
Then he does the ROS and mentions things that support acute sinusitis/allergic rhinitis.
In the ROS, he also mentions L shoulder pain. In the exam he lists the details of examining the L shoulder.
My question is, is it enough that he mentions it in the ROS and Exam that I can code for a shoulder strain, as he has listed it as a diagnosis. Also, there is no mention of how/why he has this shoulder strain. It is just stated in the exam section that the patient encountered shoulder stress x 5 days ago.
This is for an urgent care clinic and it is not computerized. The doc is old school and much of his documentation is so hard to read and (IMO) the encounter forms are not very good. Can't wait until they go electronic!
Thank you in advance!
Amy S.
