Wiki Documentation question

[angbart80]

Should radiologists always use “carotid atherosclerosis“ and never use “stenosis” in their documentation?

 

[thomas7331]

Not sure I understand the intent of what you are asking here, but this is a question that's probably best put to the radiologists themselves. Physicians need to document their impressions according to their best assessment of patient's condition according to their training and the clinical criteria that they are required to follow. It's not up to coders to say what terminology they should or should not use. In this particular case, I'm not sure whether or not atherosclerosis is a condition that can be diagnosed from an imaging study alone and perhaps they use stenosis because that is what is actually visible. But again, it's something to discuss with the radiologists themselves.

 

[angbart80]

That's what I thought. I'm trying to get a job with a coding consulting firm and they wanted a writing sample on the subject. I'm of the opinion that radiologists can't be told by us what wordage to use since they are the doctors and they are the ones doing the diagnosing. I think as coding consultants we should only encourage using specific terms and make it clear on what the diagnosis is. Stenosis seems like a broad term to me since it can be used for spinal stenosis, and things like pyloric stenosis etc. If they put carotid stenosis though, that would be specific enough for me to code from.

 

[thomas7331]

Yes, I think you're right on track from a coding perspective. It's appropriate to coach physicians for specificity and complete terminology when that information is known or suspected to be known based on content of the records, but not to steer them to specific clinical wording.