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Need help with diag. code

  1. #1
    Location
    St. Louis, Missouri
    Posts
    262
    Default Need help with diag. code
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    We had a patient that had a job physical and on this physical the doctor said he felt a hernia. The patient came to us for a second opinion. He was having no pain at all. We did not find a hernia. What diagnosis would I use?

    Melissa Blow, CPC

  2. Smile
    Quote Originally Posted by mmelcam View Post
    We had a patient that had a job physical and on this physical the doctor said he felt a hernia. The patient came to us for a second opinion. He was having no pain at all. We did not find a hernia. What diagnosis would I use?
    Take a look at V71.89 (obs/eval for other suspected conditions; other specified conditions) as your first dx, with V65.5 (person w/feared complaint in whom no dx was made) as your second dx (V71.89 is ok as 1st dx, but V65.5 cannot be 1st dx, however it completes "the story").

  3. #3
    Location
    Alexandria Minnesota Chapter
    Posts
    50
    Default
    According to the Coding Guidelines listed at the beginning of the 2009 ICD-9-CM book, V65.5 is acceptable as either 1st or Additional Dx.

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