Wiki Incidental finding in Inpatient visit

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umas86

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Please help me. In the report of Initial inpatient visit the provider has documented"Incidental left hydro nephrosis and hydroureter and nephrolithiasis". In EM can we code the incidental findings or not.Thanks in advance.
 
Whether the finding is incidental or not does not determine whether you should code it. It depends on what the clinician did about the finding.
Consider the MEAT acronym - Monitor, Evaluate, Assess, Treat
If the physician did any of those regarding the finding, or those findings impacted medical decision making, then yes, code it. If not, then do not code it.
This is an article mainly about Risk Adjustment coding but also addresses this in the beginning. https://ionhealthcarepulse.com/2016/09/28/faqs-on-risk-adjustment/
 
Thank you so much for detailed explanation. The provider referred to PCP so as per the TAMPER decision flow from the article, I assume on the basis of "Referring" I can code the diagnosis.
 
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