Should i code dx 723.8 for this report?

she803

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History: Status post cervical effusion

Exam: Portable view of the chest, 03/18/2012 at 10:30 am.

Comparison: Multiple prior studies the most recent dated March 16, 2012.

Findings: There is no change compared to the prior study. There is blunting of the left costophrenic angle unchanged compared to multiple prior studies consistent with pleural scarring.There is no consolidation, pleural effusion or pneumothorax. Heart is normal in size. There is atherosclerotic calcification of the aortic arch. Surgical clips overlie the left and midabdomen.
 

dpeoples

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History: Status post cervical effusion

Exam: Portable view of the chest, 03/18/2012 at 10:30 am.

Comparison: Multiple prior studies the most recent dated March 16, 2012.

Findings: There is no change compared to the prior study. There is blunting of the left costophrenic angle unchanged compared to multiple prior studies consistent with pleural scarring.There is no consolidation, pleural effusion or pneumothorax. Heart is normal in size. There is atherosclerotic calcification of the aortic arch. Surgical clips overlie the left and midabdomen.


Perhaps that is a typo and should say S/P Pleural Effusion? You might clarify in the medical record. Otherwise, I think you could code 793.19

HTH :)
 
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