Outpatient Radiology -New Coder

[troupe327]

Good morning, I have 2 leads telling me 2 different things regarding reason for admit.

For example, I have a patient who the reason for him coming in says "stroke,R/O Parkinson's.

One lead is telling me If in the impressions it does not indicate any findings and it comes back negative then I should not be coding that the patient had a stroke. If I don't have anything else to go on, what in the world am I coding this as?

another lead is telling me I should code the stroke, because I have nothing else to go on and the findings, not the impression do not give me any good data to derive any symptoms or reasons why they think this patient has had or is having a stroke or suspecting Parkinson's.

Confusing! Please help!

Thanks in advance!

[jmcpolin]

You would code the signs and symptoms in the case. What was going on with the patient that brought them to the hospital.