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coding from urine culture ?

N

nlaaron

Networker
Messages
97
Location
Sumter, SC
For outpt facility clinic visits, can I code results from the urine culture? The dr saw the pt for dysuria, diagnosed uti and ordered culture, but he did not comment on the results..... The results showed E Coli.
 
No a coder may not code from a lab result. A lab report has had no physician interpretation it is merely a reported result. The physician must interpret the result and determine if there is any significance. A coder does not know the difference between a specimen that has been contaminated vs one that has the significance of an organism present in the body.
 
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