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Coding from History

  1. #1
    Default Coding from History
    Medical Coding Books
    When reading a report, the history states stenosis. However in the impression, it states that no stenosis was found. Can stenosis be coded since it doesn't state rule out?
    Tracy CPC, Mt. Laurel, NJ

  2. Default history stenosis
    What I feel correct is to infer V12.59 for stenosis, history.

  3. #3
    Portland Metro
    I wouldn't code it, since there is a contradiction and therefore may be incorrect. If you are finding this is in the HPI of an office visit or admit, it may be heresay from the patient , who is remembering something they think they heard incorrectly.
    If the patient says they had a fever yesterday, but no fever is found by the doctor, you don't code it. This is the same situation

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