Radiology Coding Alert

Question: I'm uncertain about how to handle diagnosis coding for findings that have the wording "consistent with." For example, if a patient undergoes a stress test and the physician's documentation states, "Impression: Large anteroapical and ateroseptal fixed defect consistent with large infarct. No evidence for ischemia." I'm not comfortable coding this as a true diagnosis. Any advice?


Florida Subscriber

Answer: The words "consistent with" do not give a definitive diagnosis, which means you should not assume the patient has the condition that the results are "consistent with."

ICD-9-CM guidelines and the American Hospital Association's publication Coding Clinic speak to how you should handle diagnosis coding under these circumstances. Coding Clinic recommends that you treat these "consistent with" and "compatible with" situations as "probable," "possible" and "likely" diagnoses.

According to ICD-9 guidelines, "Do not code conditions that are referred to as 'rule out,' 'suspected,' 'probable,' or 'questionable.' "

Instead, if a definitive diagnosis has not yet been determined, you should report diagnosis codes for the symptoms that the patient presents with.

Try this: Talk to your physicians about how important it is for them to be accurate with their terms. Example: A patient presents with signs and symptoms of a myocardial infarct, and the nuclear imaging exam findings are "consistent with" an infarct. Chances are, he has an infarct. Tell the physician that if he can come to a definite conclusion about the patient's diagnosis, he needs to state this in his dictation so you may choose the best code.