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"Evidence of"

  1. #1
    Default "Evidence of"
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    I have started coding for a radiologist that has just begun using "evidence of" in his findings. For example, he will state the chest x-ray has evidence of scarring in the lung. I know we can not code compatible with, etc. but I have never incountered this phrase. I have researched and can not find if I can code 518.89 as if pt does had scarring in lung. Any help is very much appreciated.

  2. Default
    The phrase "evidence of" does not sound like a definitive diagnosis to me. If the radiologist sees scarring he should just state the patient has scarring of the lung.

    I would talk to the radiologist about his dictation and see if "evidence of" actually means the patient has the condition. Then let him know he needs to be clear so that you can code correctly. You could also let him know what types of phrases are acceptible when stating a patient's findings and what is considered definitive vs. speculation, etc.

  3. #3
    Default
    thank you!!!

  4. #4
    Location
    Ellenville, New York
    Posts
    1,176
    Default From Official ICD-9 coding guidelines....
    This statement from the guidelines should help:

    'Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty' (Bold is my addition). "evidence of" will indicate uncertainty on the part of the physician.

  5. #5
    Thumbs up
    Thank you, and I have already informed the rad with "evidence of" (guidelines from ICD 9) stating we can not code with these phrases.

  6. #6
    Smile evidence of
    as per Coding Clinic thrid quarter 2009, when the provider documents "evidence of " a particular condition on an outpatient radiology report, it is not considered an uncertain dx and should be appropriately coded and reported in the outpatient setting.
    hope that helps.
    Mileidy Cobo, RN, CPC.

  7. #7
    Location
    Ellenville, New York
    Posts
    1,176
    Default Wow...
    I have to catch up on my Coding Clinic reading! I didn't see that update - thanks a lot for the reference!

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