• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Probable, suspected even the word suggested?

Create Wiki
T

troupe327

Guest
Messages
30
Location
Ann Arbor, MI
Best answers
0
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!!!
 
You must log in or register to reply here.
Top