Wiki abnormal findings

[mommacode]

when coding one of the abnormal findings codes for radiology does the word abnormal actually have to be stated or can those codes be used when something is documented that doesn't have a code but is known to not be normal?

 

[tharal]

Yes, in most cicumstances it's like that...some abnormalities noted but we will not get a specific code, for eg. if some abnormalities found in EKG and the physician documents it in final impression we can add 794.31 for the abnormal EKG.

Thara L CPC H

 

[jessv1910]

I agree with Thara. Also the word "Abnormal" is in parentheses which makes it a non-essential modifier.

 

[mommacode]

the reason I ask is I was told not to code abnormal findings unless they state "abnormal" which I didn't feel was correct. If the term increased or decreased or any other findings is documented that there is no code for then I always used one of the abnormal findings codes for radiology. Now I'm so confused about the whole process I feel like I don't know what it right.

 

[jessv1910]

You are correct. You don't need the doctor to document "abnormal" in order to code an abnormal finding. This word is in parentheses so therefore its not needed. I hope this helps:
Nonessential modifiers are a series of terms in parentheses that sometimes directly follow main terms, as well as subterms. The presence or absence of these parenthetical terms in the diagnosis has no effect on the selection of the code listed for that main term or subterm.
Don't stress