Wiki coding from the impression

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mitchellde

mitchellde

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If you are coding inpatient then no you are not allowed to code form the impression, if you are coding outpatient then yes you are ALLOWED to code from the radiology report and the path report, not required. The exception for outpatient is skin lesion excisions which you are required to wait for path, everything else you may code what is known at the time of coding or you may wait for for the report from path or radiology and code from that as they have been rendered by a physician. Lab reports no you must wait for the physician to interpret the result.
 
if the information is available at the time of coding then code to highest level of specificity which has 2 meanings, one is code to the highest number of digits in the code and the other is to code the highest degree of specificity with regard to the condition, d=so if we have a symptom for the test but at the time of code we now have the definitive condition per the results then the highest level here is the definitive condition. So for outpatient or physician coding if you have the results from path or radiology the yes that is what you code and not the symptoms. So I guess it is not a you may but you should.
 
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