Budd-Chiari Malformation Type 1
I have a patient who was admitted with abdominal pain due to small bowel obstruction. Budd-Chiari malformation Type 1 is noted in her H/P PMH.
A review of her past records reveals that she was seen in May of 2017 in the ED for vaso-vagal syncope (was not admitted) and then had an MRI which revealed :
Cerebellar tonsils extending to 12 mm below foramen magnum consistent with Chiari I type malformation.
I am not sure if the Budd-Chiari should be coded or not, since there are no current symptoms, treatment or monitoring. There is not a 'chronic' option and code G93.5 is an mcc. I do believe we code asymptomatic PFOs which I have always wondered about too. What do others do?