If a patient comes in for a sinus x-ray with the ordering diagnosis codes being R51 Headache (which is not a covered dx) and J32.9 chronic sinusitis.... But the report does not show any findings of sinusitis, I wouldn't still code sinusitis correct? no priors, no documentation mentioning anything about a hx of sinusitis. An employee said that she feels we could still use that J32.9 code since it is possible the patient could of had a chronic sinusitis and may have cleared up from treatment. But I was under the impression if it's not shown on the report then I could not code it????
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