I am a Radiology coder and am looking for clarification on choosing a primary diagnosis. When a study (XR, CT, MR, etc) is done and the only finding which might be relevant to the reason for the exam is non-specific or abnormal, do I code the abnormal finding or the reason why the test was ordered? For example, a chest xray is ordered because the patient has a cough. The only finding on the xray is groundglass opacities in both lungs. Would I use 793.19 or 786.2, or both? Thanks
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Wiki Code abnormal finding or reason for exam?
- Thread starter meo59101
- Start date
Bernadette10
Guru
This is a great question. I was wondering something very similar. I'm new to all this, but the way I understand it is if the cough is a symptom of the ground-glass opacities, it would not be coded, and only 793.19 would be coded, but the cough could be coded as an "admitting diagnosis." If this is an outpatient, though, why would there be an admitting diagnosis? This is all confusing. Any advice would be appreciated.
Another example: A patient has a chest x-ray because of cough. Chest x-ray shows a 3 cm pulmonary nodule. The diagnosis would be cough, correct? Because the pulmonary nodule would be an incidental finding?
Another example: A patient has a chest x-ray because of cough. Chest x-ray shows a 3 cm pulmonary nodule. The diagnosis would be cough, correct? Because the pulmonary nodule would be an incidental finding?
aprilroc
Networker
These are great questions I would love to hear some other opinions on this issue. Are you coding the reason for the test being ordered if the findings are vague or normal? And if outpatient....then the diagnosis should be the findings? 