Wiki Abnormal Diagnostic Findings

[jenwilson@wmhs.com]

Patient had a CT scan done which showed bowel wall thickening, the doctor documented colitis stating the etiology could be infectious or ischemic. Do I code for the Colitis, Unspecified? K52.9 or would I code for the Abnormal finding R93.3?

 

[CodingKing]

Go with K52.9. This is the NOS code so if unknown if infectious this is the default code to use.

2016 ICD-10-CM guideline I.A.18 (substitute Acute/Chronic w/ Infectious/Noninfectious)

A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code. The default code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned.