Why was the procedure performed initially??
Diagnostic Coding and Reporting Guidelines for Outpatient Services, codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when an established diagnosis has not been confirmed by the physician
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are
not coded and reported unless the provider indicates their clinical significance. If
the findings are outside the normal range and the attending provider has
ordered other tests to evaluate the condition or prescribed treatment, it is
appropriate to ask the provider whether the abnormal finding should be added.
Please note: This differs from the coding practices in the outpatient setting for
coding encounters for diagnostic tests that have been interpreted by a provider.
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