|Home » Categories » ICD-9-CM Coding|
Coding Signs and Symptoms vs. Imaging Results
|Article Number: 54 | Rating: Unrated | Last Updated: Tue, Nov 16, 2010 10:13 PM|
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?
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.
There are no attachments for this article.
Viewed 4061 times since Mon, Apr 11, 2011
Viewed 886 times since Wed, Jan 30, 2013
Viewed 7464 times since Fri, Apr 22, 2011
Viewed 1355 times since Sat, Nov 26, 2011
Fatty Infiltration of the Liver
Viewed 5934 times since Tue, Nov 1, 2011
Principle Diagnosis - Colonoscopy
Viewed 2012 times since Tue, Jan 17, 2012
Viewed 6157 times since Wed, Dec 14, 2011
Viewed 2927 times since Thu, Jun 16, 2011
Back Pain with Muscle Spasm
Viewed 12026 times since Thu, Mar 31, 2011
Tricompartmental Degenerative Disease
Viewed 6407 times since Thu, Jul 21, 2011