Diagnosis controversy

[Kimberley]

Order states OVARIAN CYST....US TV/Pelvic

Scan is normal.

Is it ok to code 620.2 even though the scan was normal? Nothing else to go by

Thanks:-)

[coderguy1939]

Sounds like you need some additional information to clarify the pre-op DX. You could start by requesting an H&P. Review the Chief Complaint and determine if the patient was experiencing symptoms or perhaps the patient has a history of ovarian cyst. If you don't find sufficient info on the H&P, query the doctor.

[Kimberley]

Any other helpful suggestions?

Thanks:-)