Answer :
A patient sees the physician for chest pain, fever, and cough. the physician orders an x-ray to rule out pneumonia. applying the coding concept from icd-10-cm guideline iv.h., symptom icd-10-cm coding should be reported.
According to the scenario given an ICD-10-CM code that reflects the patient's presenting symptoms would be the right one to report since the doctor has not yet confirmed the diagnosis of pneumonia.
As chest pain, fever, and cough are the symptoms that have been reported in this case, the correct codes for these symptoms are R07.9 for chest pain, R50.9 for fever and R05 for cough. It's crucial to remember that the x-ray and any other diagnostic tests results may affect the final diagnosis and the addition of additional codes.
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"The correct ICD-10-CM coding for the patient's condition, based on the information provided and applying the coding concept from ICD-10-CM Guideline IV.H, would be:
- B97.4, Pneumonia due to Streptococcus pneumoniae
- J18.9, Pneumonia, unspecified organism
- According to ICD-10-CM Guideline IV.H, when the diagnostic statement mentions pneumonia due to a specific organism, it is necessary to assign two codes:
- one from the chapter-specific section for the condition (in this case, pneumonia) and a second code from category B95-B97 to identify the organism.
- In the scenario provided, the patient has symptoms consistent with pneumonia, and the physician is ordering an x-ray to rule it out. Since the specific organism causing the pneumonia is not mentioned, we default to coding for unspecified pneumonia.
