Resolved Medical assessment

[MaryW_64032]

Pt was picked up by EMS found sleeping in a parking lot in their car. Pt said was to tired to drive home and pulled over to sleep. Pt’s only complaint is being angry from being woke up. Brought to the ED by police but not under arrest. pt examined no acute problems and is not intoxicated. Final dx encounter for medical assessment. I was going to code Z008 and R45.4.
i Didn’t see where I can’t use the two together.
opinions would be appreciated

 

[Darcy]

Pt was picked up by EMS found sleeping in a parking lot in their car. Pt said was to tired to drive home and pulled over to sleep. Pt’s only complaint is being angry from being woke up. Brought to the ED by police but not under arrest. pt examined no acute problems and is not intoxicated. Final dx encounter for medical assessment. I was going to code Z008 and R45.4.
i Didn’t see where I can’t use the two together.
opinions would be appreciated

Z00 General examination without complaint, suspected or reported diagnosis is the appropriate category and Z00.8 should be acceptable
Regarding R45.4 - only code if confirmed as a diagnosis

 

[Lori]

Z00.8 is Encounter for other general examination

ICD-10 data is linking it to mental health in a back reference Diagnosis Index entries containing back-references to Z00.8:

• Evaluation (for) (of)
  • mental health (status) Z00.8

Perhaps code the general code Z00.00 Encounter for general adult medical examination without abnormal findings

R45.4 Hostility

Approximate Synonyms

• Hostile behavior

Clinical Information

• Tendency to feel anger toward and to seek to inflict harm upon a person or group.

Other codes that may fit
R45.2 unhappiness or R45.4 irritability & anger