Z71.1 can only be coded by itself?

anne32

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I have a chart where a patient came in to f/u on HTN, hyperlipidemia, and obesity. Pt is also concerned about swelling of her elbow, but the provider states her elbow is fine and also wants to code Z71.1. I thought Z71.1 was a stand alone code that meant there are no complaints or any other dx to code. To me I would code the HTN, Hyperlipidemia, and Obesity and not code anything about the elbow. Is this correct?
 

Deb2009

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I would code to the notes. what was the patient seen for? many times the provider selects a code just to get through the EMR record. It is the coder responsibility to review the record and code to the highest specificity. Just my two-cents worth. Hope this helps.
 

mitchellde

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I have a chart where a patient came in to f/u on HTN, hyperlipidemia, and obesity. Pt is also concerned about swelling of her elbow, but the provider states her elbow is fine and also wants to code Z71.1. I thought Z71.1 was a stand alone code that meant there are no complaints or any other dx to code. To me I would code the HTN, Hyperlipidemia, and Obesity and not code anything about the elbow. Is this correct?

The fact that the provider states there is no problem does not mean the symptom of swelling magically disappeared. The patient still has that symptom so you code the symptom. The othe way can approach it is since there was "no problem" but there is still this symptom you can look to the Z03.89 for condition ruled out and use the swelling as a secondary code to show there is a symptom and the provider has ruled out every possible diagnosis.
 
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