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Radiology Coding Alert

Reader Questions:

Or' Adds Uncertainty to Diagnosis

Published on Sat Mar 07, 2009

Question: The radiologist's impression states "superimposed atelectasis or infiltrate." Should I code both diagnoses or refer back to the signs and symptoms? Georgia Subscriber Answer: The use of the word "or" in the dictation indicates the radiologist has not made a definite diagnosis, so your hunch that you should refer back to the signs and symptoms is correct. The ICD-9 official guidelines state, "Do not code diagnoses documented as 'probable,' 'suspected,' 'questionable,' 'rule out,' or 'working diagnosis' or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit" (www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf). For example: If the patient had the exam because of a cough, you could report 786.2 (Cough).
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