CASE 1 PROGRESS NOTE This patient is a 50 year-old female who began developing bleeding, bright red blood per rectum(Patient's p
resenting complaint.), approximately two weeks ago. She is referred by her family physician. She states that after a bowel movement she noticed blood in the toilet. She denied any prior history of bleeding or pain with defecation. She states that she has had an external hemorrhoid(This is reported by the patient, but not documented in the exam or assessment, so it is not coded.) that did bleed at times but that is not where this bleeding is coming from. She is presently concerned because a close friend of hers was recently diagnosed with rectal carcinoma requiring chemotherapy that was missed by her primary doctor. She is here today for evaluation for a colonoscopy. Physical examination, she appears to be a well appearing 50 year-old, white female. Abdomen is soft, non-tender, non-distended. ASSESSMENT: 50 year-old female with rectal bleeding(Report the code documented in the assessment.) PLAN: We’ll schedule the patient for an outpatient colonoscopy. The patient was made aware of all the risks involved with the procedure and was willing to proceed. What diagnosis code(s) are reported
K62.5 is a code used in the diagnosis of rectal bleeding. form the reports she gave that she notice some blood when she made used of the toilet is a pointer to heamorrhage in the rectum or anals. cancer in colon can result into hemorrhage,
Colonoscopy is the the diagnosis of the colon to diagnosis possible cause.
The risk associated with procedure can loss of more blood and internal rupturing of the colon
because the rest of the options are them basacly them paying their own medical bills and their isn't really much help if you're paying your own medical bills but health insurance pays it for you which is basacly helping pay health insurance
