Wiki Can i use dx from order???

[Kimberley]

Physican order is for a CT sinus limited, dx: chronic sinusitis.

Report is normal other than an incidental finding of a deviated septum. Can i still use 473.9 as the dx even though the scan is normal?

Thanks-

Kimberley Tober, CPC
Franklin, TN

 

[njwanucha]

At our facility, we would code the sinusitis and the deviated septum or abnormal finding V code.

 

[nelsong5]

You should always use the diagnosis from the order made by the physician.

Even if the study came normal you will still use the diagnosis in the order.