The patient, a 19-year-old man, was transferred from another hospital with intractable headache. The accompanying CT scan was normal, but clinical symptomatology was suggestive of subarachnoid hemorrhage. Lumbar puncture, non-contrast bilateral internal carotid cerebral arteriogram, and contrast cerebral MRI were all normal. When the findings were discussed with the paptient, he became increasingly belligerent. Although his headaches were only somewhat improved, he refused further treatment and was discharged for follow-up with his own physician. Discharge diagnosis: Headache
I am not getting the correct ICD 10 code(s) for this
These procedural ICD 10 codes can be used by the previous hospital as they underwent diagnostic procedures and cannot be claimed by the currently transferred hospital
CT scan - B020ZZZ
Lumbar puncture - 009U3ZX
MRI - B338Y0Z
Discharge diagnosis can be claimed by currently transferred hospital
Headache - G44.221
The patient, a 19-year-old man, was transferred from another hospital with intractable headache. The accompanying CT...
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Case 1 Clinic Note This 57-year-old female patient comes to the clinic today for her annual physical. HEENT: Normal LUNGS: Clear ABDOMEN: Soft, nontender RECTAL EXAM: Refused NEUROLOGICAL: Congenital spastic paralysis, left leg There are no physical findings that need to be addressed at this time. I have reviewed her care plan, and she should continue per her care plan at the residential home where she resides. ICD-10-CM Code Assignment.....x........ Case 2 Sleep Clinic Note This patient returns today following...
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The following documentation is from the health record of a 42-year-old male patient. Physician Office Record Entries Hospital Copy: History and Physical Admitting Diagnosis: Herniation of intervertebral disc, L5–S1 right side Present Medical History: Patient is a 42-year-old Native American male who initially developed problems with his back in July of this year. He was treated with anti-inflammatory agents and started on an exercise program; his condition improved enough to return to work. About one month ago, he had recurrence...
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