Urology Coding Alert

Question: I know all about avoiding the coding of diagnoses using probable, suspected, and other similar terminology, but what about the term “correlation?” For instance, if a provider says findings on a computerized tomography (CT) scan correlate with a particular diagnosis, does that meet the criteria for reporting it?

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Answer: You already know you won’t find any guidance on this specific term within the ICD-10-CM guidelines. However, you should consider a widely known concept within the world of statistics to base your answer upon: “Correlation does not equal causation.” The idea similarly applies when you’re “correlating” a set of findings to a particular diagnosis. While the urologist might consider the findings conclusive, the phrasing of the operative report or patient chart does not allow you to code it as such.

In these instances, it’s best to reach out to the provider to confirm whether they believe the diagnosis is definitive — or if there’s simply a strong likelihood that the CT scan findings result in the implied diagnosis. As the diagnosis currently stands, you should code based on the signs and symptoms unless you hear otherwise from the provider.