Wiki DX after lab results

[AprilSueMadison]

Pt seen as she was concerned about a bacterial infection. Pt had no symptoms, only her concern. We swabbed. Two weeks later we received confirmation the pt did have an infection.

Can I add a dx to the office visit based on the lab results? I understand how it works with pathology/bx samples, but I not clear on something like this.

 

[mitchellde]

The lab results must be interpreted by your provider in order to be coded. this is different from radiology and pathology. If the provider amends the chart note to include this diagnosis then you may code it if the claim has not yet been submitted. If the claim has been submitted then I would not worry with a corrected claim unless needed for a denial.