Wiki Coding Echo results

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skildare

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A patient saw our cardiologist in consultation for morbid obesity with leg edema - evaluate LV function. Doctor stated in the office visit note dx of the obesity and edema. A limited echo was also performed. The echo report states the study was normal, indication for study was "Evaluation of left ventricular function in morbidly obese patient." No mention of the edema anywhere in the echo report.

Office visit was coded with 278.01 and 782.3. Echo was coded as 278.01 only. Patient called saying insurance will not pay for the 278.01 code and if the visit can be re-coded. I don't have an issue with changing the office visit to 782.3 as primary dx, leaving 278.01 as secondary. I'm unsure about the echo. My first instinct is it has to stay as is; I need to go what was in that report alone regardless of what the office note on the same day says. Yet, I feel bad that simply because Doctor did not mention the edema in that report I can't add it.

What's your opinion on this? Seems I was just reading about something similar not too long ago and I cannot find it now. I don't remember what the take was on these situations. Maybe I should ask if the report can be ammended with the additional dx.

Thanks for any input.
 
Cardiologists dont (usually) see patients for obesity, they do see them for edema. For coding, the echo is coded to show abnormal findings. If there are no abnormal findings, then the echo is coded to show the indications for the test.

Since the Physician documented the indications in the report as "Evaluation of left ventricular function in morbidly obese patient", I would verify in the OV documentation why the echo was ordered. I suspect the OV MDM note did not state "echo to eval obesity". I suspect he wanted an echo to evaluate if there were cardiac factors causing the edema. Based on what the OV documentation shows, I would question the ordering physician and see if he wanted to amend the indications in the echo report to clearly state his reason for the echo.
 
armymomryan said:
Wouldn't you code the REASON the echo was done as the diagnosis and not the RESULTS as the diagnosis? The results are after the fact, what was the reason the test was done?
Click to expand...

The final results are ALWAYS coded as the principal diagnosis. You would only code the signs and symptoms if the results are inconclusive and/or normal. AND you would NEVER use a rule out code.
 
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