Outpatient Facility Coding Alert

Published on Wed Nov 13, 2019 PDF

Question: In the impression of the report, the provider documents that “contrast opacification of the subacromial and subdeltoid bursa is indicative of a rotator cuff tear.” Is this sufficient documentation to code a rotator cuff tear?

Louisiana Subscriber

Answer: There are numerous instances where the terminology behind a particular diagnosis can rule it out from being reported as a diagnosis code. The most common offenders are terms such as “probable,” “likely,” “suspected,” etc.

However, if the provider documents that a particular set of findings is “indicative” of a diagnosis, then you may consider that diagnosis a definitive finding. In this instance, the provider is trained to identify a rotator cuff tear when the imaging presents contrast opacification of the subacromial and subdeltoid bursa. In other instances, such as the documentation of an opacity on a chest X-ray, the provider may be more inclined to speculate as to the etiological origins of the finding. If the provider speculates further beyond stating that an opacity exists, they will most likely refrain from using a term as clear-cut as “indicative.” 

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