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what is the correct ICD-9 --dd1

Dawnisha Posted Thu 01st of March, 2012 02:06:14 AM

26 yr old female was driving her car tody when she noticed sudden loss of vision in her right eyeand numbness of her right arm PT pulled over to the side of the road, both of her symptoms resolved. and she then developed a right frontal headache and presented to the urgent care center for evaluation. Pt stated this happened to her approximately 7yrs ago in just about the same manner. Physical Exam: pt is alert 7 she appears in moderate distress with complaints of right fronatl headache. HEENT is unremarkable. pERRL EOMs are intact. Funduscopic exam is unremarkable. Pt vision was tested and this was normal. NEUROLOGICAL Exam: cranial nerves are intact. Pt has good motor strength bilaterally: sensation is completely within normal limits. reflexes are 2 plus bilaterally. Plantar reflex is downgoing bilaterally. finger-to-nose and Romberg were also normal. DX: Migranine Headache. Treatment: the Pt was given an injection of Demerol 50mg and Phenergan 50mg and allowed to rest for approximately one hour. She felt improved and was discharged. She was told to make an appt with her family physician for further evaluation of this problem. She was also given a home pack of Tylenol #3 for pain

SuperCoder Answered Thu 01st of March, 2012 06:39:25 AM

code 346.90 only as numbness & loss of vision are resolved prior to his visit also no need to code 784.0 when coding 346.90

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