tci ED Coding & Reimbursement Alert - 2013 Issue 12

You Be the Coder: Get Specific With Final Aneurysm Presentation Dx

Question: What diagnosis codes would you assign for the following patient encounter? Hx: Patient is a 69-year-old mother, who is right handed and provides a history of a four day long severe headache with visual blurring and diplopia all right sided. She denied any Hx of seizures, motor sensory deficit, nausea and vomiting. No trauma or speech difficulties. She states she has had sinusitis for years. No current meds, NKDA. Physical Examination: HEENT: Right pupil 2mm, reactive. Disconjugated gaze is present. There is right sided ptosis. Oropharynx clear without lesions. Her neck is supple without lymphadenopathy or thyromeagaly. Heart...

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