Resolved Practice case

[DematriusW_69730]

So I’m doing a practice case. Fast forward, patient is being seen in an outpatient office. I coded one of the diagnosis as M79.661 & M79.662 (pain in the lower right/ left leg). I coded this b/c the encounter mentions in the HPI section, location of the pain is bilateral leg, lower. Besides that, the only other place leg pain is mentioned is in the Assesment/ Plan saying specifically, “Leg pain, bilateral” . It also mention in the chief complaint / reason for visit,” pain in both legs.”

However, the rationale of the case says “Due to documentation of pain in bilateral legs” the codes are M79.604 & M79.605” can anyone elaborate on this concept? Why is it you go with those codes when their less specific ? Does the documentation in the assessment/plan section or chief complaint/reason for visit, override HPI section when coding ? Please assist, thanks.

 

[Darcy]

I actually agree with your codes since most specific. But perhaps answer was taken only from the Assessment which doesn't state lower.

 

[DematriusW_69730]

I actually agree with your codes since most specific. But perhaps answer was taken only from the Assessment which doesn't state lower.

THANK YOU!