Coding from History

tracross

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When reading a report, the history states stenosis. However in the impression, it states that no stenosis was found. Can stenosis be coded since it doesn't state rule out?
 

ram

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history stenosis

What I feel correct is to infer V12.59 for stenosis, history.
 

Deanne N

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I wouldn't code it, since there is a contradiction and therefore may be incorrect. If you are finding this is in the HPI of an office visit or admit, it may be heresay from the patient , who is remembering something they think they heard incorrectly.
If the patient says they had a fever yesterday, but no fever is found by the doctor, you don't code it. This is the same situation
 
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