Wiki Echo: Indication vs findings

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Pillow1

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IN JUNE OF 2010 THIS WAS THE QUESTION POSTED ON THE FORUM:

Wouldn't you code the REASON the echo was done as the diagnosis and not the RESULTS as the diagnosis? The results are after the fact, what was the reason the test was done?


THIS WAS THE ANSWER:
The final results are ALWAYS coded as the principal diagnosis. You would only code the signs and symptoms if the results are inconclusive and/or normal. AND you would NEVER use a rule out code.

WOULD SOMEONE PLEASE ADVISE IT THIS IS AN ACCURATE ANSWER AS I AM FACED WITH THE SAME DILEMMA ?

THE CONDENSED ECHO REPORT IS ATTACHED

INDICATION FOR EVALUATION: Valvular heart disease.


CONCLUSION:
1. Echocardiographic/Doppler study with technical limitation.
2. Overall, preserved left ventricular function.
3. Normal cardiac chamber size.
4. No pericardial effusion.
5. Trace-mild aortic insufficiency.


ANY FEEDBACK IS GREATLY APPRECIATED/ DENISE
 
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I would concur. Read your ICD-9 guidelines for patients receiving diagnostic services. The findings/impressions are coded. In the absence of those, the reason the exam was ordered would be used. Because the insufficiency is "trace" I'd be hesitant to code that and would go with the reason for the echo.
 
Well, I would like to give my openion:

Valvular heart disease.............]
Trace-mild aortic insufficiency. ]........ These are the conditions on issue.
Valvular heart disease is a general term used for all/ some /any of the valves of the heart-like mitral, or tricuspid or aortic or pulmonary valve involvement. It is NOT SPECIFIC FOR ONE PARTICULAR VALVE of the heart.

Wheras the term AORTIC VALVE involvemnet- be it mild/trace or moderate or severe, it is an involvement of the valve and it is a lesion in the valve and not normal, producing insufficiency.. IT IS MORE SPECIFIC, WITH THE HIGHER SPECIFIC DETAILS OF A SINGLE VALVULAR INVOLVEMENT OF THE VALVULAR LESION(S) OF THE HEART.

So I would like to code for Trace-mild Aortic Insufficiency - 424.1
 
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