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Question:
A progress note from our nurse practitioner (NP) indicated that she was called by nursing to see a patient due to “unequal pupils.” The NP ordered a CT/CTA to rule out associated dissection or blood clot post angiogram earlier today. Would it be correct to assign a diagnosis code for unequal pupils as primary?
Answer:
If the exam was negative for anything that would cause the unequal pupils, then a code from H57 for unequal pupils should be your primary code.
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