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How to code when symptoms are gone ?

  1. #1
    Salt Lake North
    Cool How to code when symptoms are gone ?
    Medical Coding Books
    Patient is at home and falls. No trauma, just a little sore. Pt tells adult children that she fell a few days previously, and her children bring them to our clinic for an exam. Per medical records, pt bruising, no residual pain of any kind, no abnormalities of joints or skin. This was the main focus behind the visit. With all of the symtoms gone, how do we code them?

  2. #2
    Worried well V65.5 Or Observation V71.89

  3. #3
    I would probably use V71.4 and V15.88

    Laura, CPC

  4. #4
    V71.4 won't work due to states after motor vehicle accident but V15.88 history of fall will

  5. #5
    V71.4 is Observation following other accident, that means any other accident that doesn't have a specific code. The only specified one is the at work which would be V71.3. The comment about the motor vehicle accident is just an example, not the only thing it can be used for.

    Laura, CPC

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