Cardiology Coding Alert

Question: My cardiologist ordered a retroperitoneal ultrasound with the admitting diagnosis header saying, "AAA," and the clinical history header saying, "Possible AAA." The impression says, "Negative ultrasound examination of the abdominal aorta, with no evidence to suggest an abdominal aortic aneurysm." The cardiologist gave AAA as the diagnosis for the exam. Can I use this diagnosis even when the exam is negative?

Indiana Subscriber

Answer: Evidently your cardiologist hadn't confirmed that the patient had an abdominal aortic aneurysm because it didn't show up on the ultrasound. And if the aneurysm wasn't confirmed, he should have given the patient's signs or symptoms or other reason why he thought the patient might have an aneurysm.

Unfortunately, you don't have that information, so you will need to go to your cardiologist for clarification.Z

The official ICD-9 guidelines instruct you not to code a diagnosis documented with terms indicating uncertainty for office and outpatient services (www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide06.pdf).

Even for short-term, acute care, long-term care and psychiatric hospitals, you can only code an uncertain diagnosis as if it exists if the diagnosis is still uncertain at discharge, the guidelines say.