What are the appropriate diagnosis codes to report Mayer-Rokitansky-Küster-Hauser syndrome? The physician documented congenital absence of the uterus and vagina.

This condition is reported with International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes representing the clinical presentation. Codes Q51.0 (agenesis and aplasia of the uterus) and Q52.0 (congenital absence of the vagina) represent the manifestations the physician documented. Additional codes may be reported for any additional manifestations documented (eg, renal abnormalities, scoliosis).

When our patients with ongoing or chronic medical conditions return for follow-up visits, the parents often state that the reason for visit is follow-up without further indication of the reason for visit. May we supplement the documentation of chief complaint beyond the patient’s or caregiver’s own words?

Yes. While the documentation guidelines for evaluation and management services describe the chief complaint as usually stated in the patient’s own words, the chief complaint may also...

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