An infant presents to the Emergency Department for suspected burn injury possibly caused by hot water while bathing. The physician checked the baby and determined that there was no burn injury. What code is more appropriate, Z04.3, Encounter for examination and observation following other accident, or code Z04.8, Encounter for examination and observation for other specified reasons? In addition, is it appropriate to assign an external cause code from chapter 20 to provide additional detail about the cause of the suspected injury?
The external cause code indicates an injury, health condition or adverse effect has occurred, and these codes are not assigned without a documented injury, health condition or adverse effect. Assign only code Z04.3, Encounter for examination and observation following other accident, as the first-listed diagnosis. It would not be appropriate to use an external cause code, because no injury, health condition or adverse effect was found after examination.