I'm having the same problem with round 3. Did you by chance, complete round 3.
HISTORY OF PRESENT ILLNESS: Patient presented with hair spray exposure to right eye.
REVIEW OF SYSTEMS: Complains of pain. No fever, nausea or vomiting.
EXAMINATION: HEENT: Bilateral ear canals: ear drums normal. Oropharynx: unremarkable. Fluorescein stain done of right eye: shows 1 ml area of corneal abrasion. Bilateral pupils reactive. Anterior chamber bilaterally normal. CHEST: Bilateral good air entry, clear to auscultation, no rales, rhonchi, rubs, normally resonant. CVS: CVS â€” S1, S2 positive, normal split, no thrills, bruits, rubs or murmurs. ABDOMEN: Soft, non-tender, no organomegaly, no free fluid, no abnormal masses, no rebound. CNS: AAO x 3, no focal neurological deficits, no cranial nerve deficits, no cerebellar or meningeal signs, bilateral power 5/5.
ASSESSMENT: Right eye corneal abrasion.
PLAN/EDUCATION: Ciprofloxacin ophthalmic 2 drops q2h while awake x 2 days, then q4h while awake x 5 days. Use dark glasses. Follow up in one week. May take Ibuprofen or Ultram for pain.
I have cpt 99202 and icd-9 code 918.1 for the corneal abrasion. I can not get the system to take anything for the exposure of hairspray to the eye? The only other thing I could think to code is for the fluorescein stain, but from what I have seen, that is included in the office visit. So sorry for posting a question to your question, just hoping you could point me to the right direction. I'm a little frustrated to say the least. I hope someone is able to help you with your question.
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