Wiki reason for exam vs findings in report

[crdavid]

I have a question regarding the reason for exam (dx from order) and the findings after the scan has been completed. In the example below the reason for exam is elevated PSA (R97.20) and in the findings it states 3 lesions found (N42.9)

Would you code both R97.20 and N42.9

or would you only code N42.9 Lesion since this is a symptom of elevated PSA?




REASON FOR EXAM:
Elevated prostate specific antigen [PSA]

ADDITIONAL HISTORY:
Elevated PSA.

TECHNIQUE:
Multi-parametric 1.5 Tesla MRI of the prostate/pelvis was performed using a phased-array torso surface coil, including multiplanar T2WI, axial T1-weighted images, high b value axial DWI, and dynamic post-contrast FSPGR images (DCE) are performed with 10 mL Gadavist. Colorized hybrid parametric semi-quantitative perfusion maps also performed with positive enhancement integral and maximum slope of increase being analyzed.

COMPARISON:
None.

FINDINGS:

Prostate size: Prostate measures 4.9 x 3.7 x 4.8 cm for an estimated ellipsoid volume of 46 cc.


IMPRESSION:
Three lesions are identified with no obvious high grade malignancies.

 

[Eljones]

If it were me, I would code both.

 

[ItsJustFaith]

I would only code n42.9 based on the coding guidelines


a.
Use of symptom codes
Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
b.
Use of a symptom code with a definitive diagnosis code
Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code.
Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

I have a question regarding the reason for exam (dx from order) and the findings after the scan has been completed. In the example below the reason for exam is elevated PSA (R97.20) and in the findings it states 3 lesions found (N42.9)

Would you code both R97.20 and N42.9

or would you only code N42.9 Lesion since this is a symptom of elevated PSA?




REASON FOR EXAM:
Elevated prostate specific antigen [PSA]

ADDITIONAL HISTORY:
Elevated PSA.

TECHNIQUE:
Multi-parametric 1.5 Tesla MRI of the prostate/pelvis was performed using a phased-array torso surface coil, including multiplanar T2WI, axial T1-weighted images, high b value axial DWI, and dynamic post-contrast FSPGR images (DCE) are performed with 10 mL Gadavist. Colorized hybrid parametric semi-quantitative perfusion maps also performed with positive enhancement integral and maximum slope of increase being analyzed.

COMPARISON:
None.

FINDINGS:

Prostate size: Prostate measures 4.9 x 3.7 x 4.8 cm for an estimated ellipsoid volume of 46 cc.


IMPRESSION:
Three lesions are identified with no obvious high grade malignancies.