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Diagnosis Based Upon Presenting Problem

  1. #1
    Question Diagnosis Based Upon Presenting Problem
    Medical Coding Books
    I work for several large ED sites. If a patient presents to the ED with a "feared condition" such as a foreign object in nose but upon exam the ED physician finds nothing wrong with the patient; can you code by the presenting problem (i.e. foreign object in nose) or do you have to use a V code which most Payers will not cover.


  2. #2
    St. Louis, Missouri
    I would code the symptoms. What made them think that they had a foreign object in their nose? Code whatever symptoms they gave for this.

    Melissa Blow, CPC

  3. #3
    Louisville, KY
    In the event you have no reported signs/symptoms, assign V71.4 (or something similar and to your liking). If the provider did document symptoms, I'd report those first, followed by V65.5.

    Good luck.

  4. #4
    Default "feared" or "suspected condition"
    I also work for ED and many times we get children with suspected FB, or suspected injestion, when there are no signs or symptoms for DX, I use V71.9 I usually do not have a problem with reimbursement

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