PCMA Chapter 15-"Sophia DiStefano, a 5-year-old female, is seen by Dr. Salpega. He diagnoses Sophia with...

PCMA Chapter 15-"Sophia DiStefano, a 5-year-old female, is seen by Dr. Salpega. He diagnoses Sophia with bilateral chronic serous otitis media because this visit is the third bout of otitis media she has had within the past seven months. Dr. Salpega asks that David Dolan, a Registered Medical Assistant, conduct an audiometry screening on Sophia. He also suggests that Edvige, Sophia's mother, consider having Sophia undergo a bilateral tympanostomy and tube placement for a more permanent treatment of the chronic otitis media."

Why is it necessary for David to code for the specific condition chronic serous otitis media rather than a nonspecific condition such as otitis media?
Why must David be sure to code for the bilateral nature of the condition?
What are the benefits of having over 70,000 diagnosis codes?

Expert Solution

David specified the condition to be chronic serous otitis media as it was the third time that she had the same condition in the past 7 months. Recurrence of AOM(Acute Otiitis Media) is the most common cause for Chronic serous otitis media.Also, if the causes where non specific like otitis media or otitis externa the patient would be having pain, fever or some other symptoms

Secondly David was sure to code for the bilateral nature of the condition as audiometry reveals that both ears have been affected. Audiometry and tympanometry are the investigations to be done in this case and reveals if it is unilateral or bilateral

Diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters.Thus aving more than 70,000 diagnosis codes help in easy identification of the disease and its further management.

Nightingale answered 2 years ago

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