return to work after MVA

tag60

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Pt needs release to return to work. I understand I would code the reason why he was not able to work, but in this note I can't come up with anything solid. Please take a look and tell me how you would code this. Details are sparse as to type of accident or even if pt went to ER or elsewhere, but pt now comes to PCP and asks for note to return to work.

S: Pt had MVA in parking lot 4 days ago. He wants to go back to work. He is able to walk.
O: Covers basic systems (heart, lungs), plus mentions "Knee brace on for protection."
A/P: He is able to start work. Start with light duty.
Then he lists but does not address in note or do anything for the following:
Chronic pain,
Hep C carrier,
Allergic rhinitis.

What diagnosis code can I use? Should I go with Z02.79, issue of other medical certificate?
I also considered Z04.1, encounter for exam and observation following transport accident, but I'm just not sure this really fits this scenario.

Thanks for taking a look at this!
 

gramckoam

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Hi: May be the patient are looking for one specific form; we use one in our medical center the name is Incident Report, and keep the document on chart, them the encounter is for administrative, but is the patient was seen by the doctor the encounter is office visit and code with manifestation.
Thank you. :D
 
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