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Auditing subsequent care visit

  1. #1
    Cool Auditing subsequent care visit
    Medical Coding Books
    A patient with a newly diagnosed stroke is seen by the neurologist in follow up. A detailed exam is performed. For MDM notes:
    R hemispheric infarct
    repeat CT head R (illegible word) infarct with hemorrhagic (illegible word)
    will check MRI head tomorrow to determine extent of stroke/hematoma
    will hold antithrombolytics for now
    will follow.

    The overall risk I can see is high, but the established diagnosis of rt hemispheric infarct would be 2 points for est problem worsening due to hemorrhagic... MDM would only meet low 99231.
    Is there a possibility that the hemorrhage would be the second problem for another 2 points to make this high MDM?

  2. #2
    Question Help-diagnosis code
    In this scenario would there be one diagnosis of 434.91 for the Rt hemispheric infarct? or would there a second diagnosis code for rt hemispheric infarct with hemorrhagic (illegible word)?

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