Wiki Coding from Diagnostic report summary in H&P notes

[Praveen Ravi]

Documentation goes like this..

radiology: Ultrasound of the gallbladder with mild gallbladder wall thickening, no pericholecystic fluid, moderate-sized gallstones in the region of the neck of gall bladder. UA with trace blood. CT of the abdomen and pelvis with gall stones visible, dilated gallbladder, mild intrahepatic ductal dilation, simple hepatic cyst, left hepatic lone, otherwise normal.

Impression and plan: A 68- yr-old female with severe epigastric and RUQ abdominal pain., now resolved, a normal WBC count , Normal LFT, I have discussed the risk, benefits and alternatives to the patient. At this time, she is leaning towards possible low-fat diet, Actigall. I do have some concerns given dilation of the gallbladder on CT. I will order a HIDA to evaluate for cystic duct obstruction and will proceed accordingly. She is in agreement with this plan.

AND THE QUESTION IS....
Will you code cholelithiasis here since its mentioned on Radiology?? Whether it need to be confirmed again in Impression notes to code it?

 

[Dhaneshmurali]

Cholelithiasis

Hi,

Yes. Mostly in radiology charts diagnosis is taken from impression only. If none of the condition is mentioned in impression then we will take signs and symptoms from RFE (reason for visit).


If no signs and symtpoms means then we will take diagnosis condition from reason for visit or radiology findings directly without noted in impression.


In your scenario RUQ and epigastric pain is relalted to gallbladder related condition, so we can take cholelithiasis from radiology findings.


Regards,
Dhanesh M

 

[sivakumar.msc20@gmail.com]

Yes, i agree.