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Wiki No IMPRESSION documented

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solocoder

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I would sure love to get a clear answer on this one... I've just started coding some radiology and I'm finding that these radiologists do not always document an "impression". Just "findings". Even though the "findings" could explain the signs and symptoms, and are the same diagnoses that they do often include in an "impression" (WHEN they do dictate one). Can I just code from those "findings"? Or stick with the signs and symptoms?

Thanks in advance for any help!
 
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