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Wiki Vertigo assessment

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als695

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Grand Forks, ND
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Hello!

I'm a new coder and I think I know the answer to my own question, but I would just like a 2nd opinion.

I am coding an urgent care visit. Diagnosis is otitis media, Pharyngitis and Vertigo. He has documented enough for the OM and pharyngitis, but there is really nothing to support the vertigo dx. In the ROS under Neuro, he has circled "dizzy". However, it is not mentioned ANYWHERE else on the encounter form. I know that dizziness can certainly be caused by ear problems, but I'm not comfortable putting "vertigo" as a dx. I just coded for the OM and Pharyngitis. Am I right?

Thanks for any insight you can offer!

Amy
 
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