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Coding Signs and Symptoms vs. Imaging Results


Question

The out patient’s order lists signs and symptoms for the chest x-ray. The report comes back negative. Do we code from the report or can we use signs and symptoms?

Answer

Coding rules allow you to do either.  The official guideline is: 

For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign V72.5 and a code from subcategory V72.6. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the V code and the code describing the reason for the non-routine test. For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

Disclaimer: All articles intended for general guidance only and not as a recommendation for a specific situation. Readers should consult an official source (AHA, AMA, etc.) or a qualified attorney for specific legal guidance.

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