Probable, suspected even the word suggested?

troupe327

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I understand the outpatient guidelines to code the reason for exam if there are no summaries, impressions etc or a negative examination. however, in these instances where there is a impression which indicates uncertainty suspected, probable even suggested..the guidelines states that cannot be coded but only code to the highest specificity.

Here is an example of the impressions section for a patient who's reason for exam was vertigo 7804.
I know I can't code ischemic disease because of this word "suggesting" because it sounds uncertain or at least among those words anyway. Could a code of 4599 be picked up or just leave that alone and code it out to the reason for exam 7804?

Impression:
1. No evidence of acute intracranial process.
2. Areas of of increased T2/FLAIR signal suggesting chronic small vessel
ischemic disease.
Thanks...AGAIN!!!
 
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