May 31st, 2015 - yolieg
followup for cochlear implant no where in any of the notes states reason for the implant
I asked the auditor to look at encounter and this was here response
Office/clinic note documents patient recently had a lens transplant. Sutures were removed today and will follow up. So we need to find out more of what is going on here. Ambulatory clinical discharge summary give a diagnosis of granuloma annulare 695.89, hmm not much help.
I found nothing in orders tab or results review tab. So I would code the granuloma annulare, the s/p lens transplant and the suture removal documented in your office note. V43.1 for lens replacement status and V58.32 encounter for removal of sutures.
There is enough there to code and if anymore information gets added to chart, they will put it back in the work queue to be coded again.
I am saying the is the past history what about the followup for cochlear implant?