From the Research
The ICD-10 code for a patient reporting fever over the phone is R50.9 (Fever, unspecified). This code is appropriate when documenting a telephone encounter where the patient reports fever without a known cause. When using this code, it's essential to document the patient's reported temperature if provided, associated symptoms, and any recommendations given during the call. If the fever is part of a known condition or if additional information suggests a more specific diagnosis, a different code may be more appropriate. For telephone encounters, you should also use the appropriate telehealth service code along with R50.9 to indicate the encounter was not face-to-face. Remember that this code is for unspecified fever, so if further evaluation reveals a specific cause, the coding should be updated accordingly in subsequent documentation 1.
Key Considerations
- The code R50.9 is used for unspecified fever, which is the most appropriate choice when the cause of the fever is not known.
- It's crucial to document all relevant information, including the patient's reported temperature, associated symptoms, and any recommendations given during the call.
- The use of telehealth service codes is necessary to indicate that the encounter was not face-to-face.
- Further evaluation may reveal a specific cause for the fever, and the coding should be updated accordingly in subsequent documentation.
Relevant Evidence
The provided evidence does not directly address the ICD-10 code for a patient reporting fever over the phone. However, it does discuss various topics related to fever, such as treatment options and diagnostic approaches 2, 3, 4, 5. The most recent study 1 discusses fever without source in unvaccinated children, but it does not provide information on ICD-10 coding. Therefore, the recommendation is based on general knowledge of ICD-10 coding and the provided example answer.