Results 1 to 3 of 3

dx for no injury wcomp

  1. Default dx for no injury wcomp
    Medical Coding Books
    I bill Indiana Workers Comp and I cant fiqure out a dx code for this patient please see attached dictation I will add a E code but Im still looking for a primary dx please help

    CHIEF COMPLAINT: Over all check up- rolled Bobcat

    HISTORY OF PRESENT ILLNESS: This is the initial visit for Kenneth Roberts, a 50 year-old male, His pain level is 0/10. Patient states he has been with the company for 3 years. Patient states he was in a bobcat going up a hill, lifting up a log, when the bobcat started to jump around and flipped slowly back. Nothing was hurt and he has no pain. Patient states supervisor wanted him checked out. Gwen Davis, CMA

    REVIEW OF SYSTEMS: Musculoskeletal: Negative for pain, weakness, joint stiffness. Neurological: Negative for headache, numbness, tingling. Endocrine: Negative for diabetes, thyroid disease.

    PAST, FAMILY AND SOCIAL HISTORY: Current Work Status: Working full time. Marital Status: Yes Prior Surgery: Yes - left eye Smoking: No



    VITAL SIGNS: Height: 70 inches. Weight: 185 pounds. BMI: 26.6 [Overweight]. Blood Pressure: 122/84. Pulse: 64/min. Respirations: 12/min.

    PHYSICAL EXAMINATION: Inversion of bobcat, patient inside, but restrained. Patient is A&A, Ox4. He recalls incident. He denies any HA, dizziness, pain or discomfort. He has good ROM of his neck and back and no discomfort with palpation. He has no discomfort with palpation over entire spine. He has good pulses, sensation, grip, capillary refill, ROM and resisted ROM of upper extremities. He has normal gait, his CN II-XII are intact. PEARRLA. No c/o dizziness immediately after incident. Patient denies any nausea either at time of exam or immediately following accident. No discomfort with palpation and pressure laterally over his rib cage or over T-spine and sternum. Abdomen is soft/non-rigid. Judith L Smith, PA-C

    DIAGNOSIS: No pain or discomfort with ROM (after inversion of bobcat). No LOC.

    MEDICAL DECISION MAKING: Exam. Provided patient with Biofreeze, in case he begins to stiffen up this evening or in the morning. Shown some stretches for neck, to do as needed.

    TREATMENT PLAN: Patient understands he may return for any problems or concerns.

    MEDICAL CAUSATION: This problem is related to work activities.

    WORK CAPACITY: Patient can return to regular duty. Released.

    Thank you Melissa

  2. #2
    Columbia, MO
    Use V71.3 for observation following accident at work with nothing found and use the E code secondary.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Fayetteville, NC
    I agree with mitchellde
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

Similar Threads

  1. Lumbar Myofascial injury and Shoulder soft tissue injury
    By calicoder10 in forum Emergency Department
    Replies: 2
    Last Post: 09-25-2015, 01:37 PM
  2. Board certified to bill wcomp?
    By tomtom2 in forum Billing/Reimbursement
    Replies: 2
    Last Post: 12-29-2014, 12:42 PM
  3. Injury Dx with no know Injury what E code ?
    By Karen Powell in forum Emergency Department
    Replies: 1
    Last Post: 07-11-2012, 11:54 AM
  4. Replies: 1
    Last Post: 01-26-2011, 04:44 PM
  5. cardiac injury and induced hypoxic injury
    By Trendale in forum Diagnosis Coding
    Replies: 0
    Last Post: 09-29-2009, 01:59 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.