Wiki Coding ICD-9 of Echocardiogram reports ?

[clopez]

Hello,

My question is, am I a certified coder able to code diagnosis of the Echocardiogram Conclusion report?

This is what I found in Coding clinic and my interpretation is that we can't. That we must wait until the physician confirms the diagnosis in a progress note. These are performed in a office setting and not inpatient setting.

Coders are not allowed to assign codes directly from impressions included on diagnostic reports, such as x-rays, MRI, CT scans, electrocardiograms, echocardiograms, and pathology, even if a physician has signed the diagnostic report. The diagnosis must be confirmed by the physician in the body of the medical record (eg, progress notes or discharge summary) before it can be coded. However, if the diagnostic report is adding specificity to an already-confirmed (physician-documented) diagnosis, then the coder may use the more specific code based on the diagnostic report without obtaining physician confirmation (AHA Coding Clinic for ICD-9-CM, 1999, first quarter, page 5).

Thank you!

 

[mitchellde]

That response in the coding clinic is directed to inpatient facility coders. Diagnostic reports are physician interpreted and signed. So a physician coder regardless of whether the patient is inpatient or office/outpatient, and outpatient facity coders may code the diagnosis from the diagnostic report. Since lab reports are not physician interpreted, the coder may not code from a lab report.