Admissão para broncofibroscopia após pneumonia por Legionella

"Doente admitido para broncofibroscopia (BFC), assintomático, após internamento anterior por pneumonia a Legionella.
 A BFC foi normal.
 Qual o diagnóstico?
 Ruled out? 
 Mas de quê, se o doente estava assintomático?"

(Responde Fernando Lopes)
 
 
Os códigos de observação por condições suspeitas, sem sinais ou sintomas que, depois do estudo, se excluem (são 'ruled out') só podem utilizar-se nessas situações:
 
Z03 Encounter for medical observation for suspected diseases and conditions ruled out
This category is to be used when a person without a diagnosis is suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is ruled out.
This category is also for use for administrative and legal observation status.
 
Excludes 1:
contact with and (suspected) exposures hazardous to health (Z77.-)
encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out (Z05.-)
person with feared complaint in whom no diagnosis is made (Z71.1)
signs or symptoms under study - code to signs or symptoms
 
No questão colocada o doente veio fazer um estudo após o tratamento de uma doença.
Trata-se de um seguimento ou 'follow-up' que se enquadra em: 
 
Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Medical surveillance following completed treatment
Use additional code to identify any applicable history of disease code (Z86.-. Z87.-)
 
Excludes1:
aftercare following medical care (Z43-Z49, Z51)
surveillance of contraception (Z30.4-)
surveillance of prosthetic and other medical devices (Z44-Z46)
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