lundi 21 septembre 2015

Post Radiation Syndrome

I am looking for some assistance in how to code post radiation syndrome. The Documentation reads

"Patient has history of Other (CA of Larynx) cancer.
Pt had XRT followed by 2 courses of Chemo 3 yrs ago.
Pt now has Laryngeal scarring with difficulty breathing/speaking and swallowing.
CA is resolved.
Pt to undergo Laryngectomy tomorrow

Pt has chronic pain in upper chest secondary to post radiation syndrome.
Patient does not have a pain management plan.
Patient experienced pain Almost constantly over the last 5 days.
Patient reports that over the past 5 days, pain has made it hard to sleep at night.
Patient is limiting their day to day activities because of pain.
Status - controlled.
Continue current treatment"

I am looking at coding the signs and symptoms since there is not a code for the listed post radiation syndrome.

Please provide the rational behind any responses.
Thank you


Post Radiation Syndrome

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