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Wiki DX Coding
- Thread starter cjacobs
- Start date
btadlock1
Guest
I probably would. You're looking at a diagnostic procedure report, right? As long as there's no note on there that says "inconclusive", then that's probably as definitive as they're going to get.
Hi,
An article from Coderyte may help you at this time:
"The first official indication that the rule about not coding “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis” actually applies to other equivocal terms as well--besides just those five listed explicitly in the ICD-9-CM Official Guidelines for Coding and Reporting came in a letter from the Central Office on ICD-9-CM to CodeRyte, Inc. dated Oct. 8, 2003 in a response to a question posed by CodeRyte. (CodeRyte wanted to know whether “…consistent with…” and a few other frequently-used expressions were officially “equivocal” and so couldn't be used for coding purposes.) Here is the key content from their Oct. 8, 2003 response:
“As indicated in [CodeRyte's] correspondence, other terms that indicate an uncertain diagnosis include (but are not limited to) ‘consistent with,' ‘compatible with,' indicative of,' ‘suggesting,' ‘suggestive of,' ‘apparent,' ‘consider,' ‘low probability of,' ‘high probability of,' ‘evidence of,' ‘likely,' and ‘seemingly.' The term ‘borderline' does not necessarily indicate uncertainty. Proper determination would depend on how the physician has documented ‘borderline' in the record"
As per the above documentation, we could not code for "consistent with" or "compatible with" diagnosis codes.
Thank you and have a great day!
Purnima S, CPC
An article from Coderyte may help you at this time:
"The first official indication that the rule about not coding “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis” actually applies to other equivocal terms as well--besides just those five listed explicitly in the ICD-9-CM Official Guidelines for Coding and Reporting came in a letter from the Central Office on ICD-9-CM to CodeRyte, Inc. dated Oct. 8, 2003 in a response to a question posed by CodeRyte. (CodeRyte wanted to know whether “…consistent with…” and a few other frequently-used expressions were officially “equivocal” and so couldn't be used for coding purposes.) Here is the key content from their Oct. 8, 2003 response:
“As indicated in [CodeRyte's] correspondence, other terms that indicate an uncertain diagnosis include (but are not limited to) ‘consistent with,' ‘compatible with,' indicative of,' ‘suggesting,' ‘suggestive of,' ‘apparent,' ‘consider,' ‘low probability of,' ‘high probability of,' ‘evidence of,' ‘likely,' and ‘seemingly.' The term ‘borderline' does not necessarily indicate uncertainty. Proper determination would depend on how the physician has documented ‘borderline' in the record"
As per the above documentation, we could not code for "consistent with" or "compatible with" diagnosis codes.
Thank you and have a great day!
Purnima S, CPC
JulesofColorado
Expert
Per Coding guidelines on outpatient encounters:
I. Uncertain diagnosis
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.
I would not code compatible with or consistent with on any outpatient encounter.
I. Uncertain diagnosis
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.
I would not code compatible with or consistent with on any outpatient encounter.
jgf-CPC
Guest
I agree with the code-ryte information. The RBMA or ACR is where you could find information for radiology coding.
http://rbma.org/ or
http://www.acr.org/default.aspx
http://rbma.org/ or
http://www.acr.org/default.aspx