Results 1 to 7 of 7

"Evidence of"

  1. #1
    Default "Evidence of"
    Exam Training Packages
    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
    thank you!!!

  4. #4
    Ellenville, New York
    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
    Ellenville, New York
    Default Wow...
    I have to catch up on my Coding Clinic reading! I didn't see that update - thanks a lot for the reference!

Similar Threads

  1. """Looking for on Remote coding Possition""".
    By in forum Resume Postings
    Replies: 2
    Last Post: 06-15-2014, 11:13 PM
  2. "Evidence of.." coding
    By AdamShoop in forum Interventional Radiology
    Replies: 0
    Last Post: 01-30-2014, 12:20 PM
  3. "Double-Dipping" article in "Cutting Edge"
    By ollielooya in forum Medical Coding General Discussion
    Replies: 9
    Last Post: 08-12-2013, 02:59 PM
  4. Trying to code "interstitial prominence" and "peribronchial thickening" using 2007
    By vazquecj in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 03-10-2010, 08:39 PM
  5. Chief complaints: "URI" / "Flu-like symptoms"
    By phillipmanning in forum Emergency Department
    Replies: 2
    Last Post: 11-23-2009, 11:26 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.