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Wiki Unilateral lower extremity venous duplex

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donnagullikson

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I know as coders we're not to assume but I need to know if I'm coding this correctly because I feel as if I am assuming the diagnosis in the following report.

The report that came over is a lower venous duplex scan showing reason for exam as "pain" and under the indications showing "limb pain". I'm combining all this info and coding as left lower limb pain. Is this okay or does the radiologist have to say "left lower limb pain" together?

Thanks,
 
One could clearly make the assumption that the limb pain is directly related to the location of the scan. Where does it indicate the side as the LT side? I don't know that I'd go as far as to include the "lower" part, only because there is a chance that the pain might be throughout the entire leg.
 
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