Can you help me with a diagnosis for two new patients (siblings) in a boating accident with no injuries and normal exams?
I'm having trouble assigning an E/M since nothing was diagnosed. Also, what would the ICD-9 diagnosis be? Would this be a "worried well" diagnosis? Provider chooses 959.9 (see note below), but I see no documentation of an injury per se. Here's the note for the first patient:
First note: A 2-year-old is here with mother with concern that family was in a boating accident yesterday. Per mother, they were in a small motor boat when the wake from a larger boat caused their boat to flip over and the child was trapped under the boat for about 1 minute. The boat flipped right-side up spontaneously and the child was still in the boat, wearing a life jacket. The child was responsive. No known LOC, no cyanosis. Mother states she started vomiting water. 911 was called and child evaluated on site. Paramedics said child was well enough to go to ER in private vehicle. Child never went to ER.
Per mom, child acting fine today. Good energy level. Eating & drinking well. No fever. No nausea/vomiting.
Exam: (Provider goes over all systems, and all within normal. No abnormal findings at all.)
Assessment: Submersion or drowning due to boat overturning, occupant of small unpowered boat injured, 959.9
Plan: Send for stat chest x-ray. Supportive care. Reassured mom that child has normal exam today. Follow up in 1 week or sooner if child seems worse.
ALSO, second note for sister. I'm just providing HPI here. Provider did detailed exam, with no abnormal findings:
Sister, 6 years old, also in boat at time. She jumped out before boat flipped and was not trapped. Provider gives same diagnosis as above. Plan for this patient is "close observation, return for well child check as scheduled." What would you assign for this patient? Worried well?
Thanks so much for your help!
I'm having trouble assigning an E/M since nothing was diagnosed. Also, what would the ICD-9 diagnosis be? Would this be a "worried well" diagnosis? Provider chooses 959.9 (see note below), but I see no documentation of an injury per se. Here's the note for the first patient:
First note: A 2-year-old is here with mother with concern that family was in a boating accident yesterday. Per mother, they were in a small motor boat when the wake from a larger boat caused their boat to flip over and the child was trapped under the boat for about 1 minute. The boat flipped right-side up spontaneously and the child was still in the boat, wearing a life jacket. The child was responsive. No known LOC, no cyanosis. Mother states she started vomiting water. 911 was called and child evaluated on site. Paramedics said child was well enough to go to ER in private vehicle. Child never went to ER.
Per mom, child acting fine today. Good energy level. Eating & drinking well. No fever. No nausea/vomiting.
Exam: (Provider goes over all systems, and all within normal. No abnormal findings at all.)
Assessment: Submersion or drowning due to boat overturning, occupant of small unpowered boat injured, 959.9
Plan: Send for stat chest x-ray. Supportive care. Reassured mom that child has normal exam today. Follow up in 1 week or sooner if child seems worse.
ALSO, second note for sister. I'm just providing HPI here. Provider did detailed exam, with no abnormal findings:
Sister, 6 years old, also in boat at time. She jumped out before boat flipped and was not trapped. Provider gives same diagnosis as above. Plan for this patient is "close observation, return for well child check as scheduled." What would you assign for this patient? Worried well?
Thanks so much for your help!
DX for boating accident, no injuries
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