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chest x-ray diagnosis

  1. Default chest x-ray diagnosis
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    Chest x-ray report reads rule out infiltrate. History is ? pneumonia. Conclusion states that there are no acute abnormalities. However, during this patient's stay a Chest CT and a previous chest x-ray state that the patient does have pneumonia.

    Would it be correct to use 486 for this chest x-ray performed several days later?

    Thank you.

  2. #2
    Default
    If the chest xray report does not state pneumonia, you cannot use the 486. Based on the report, you may just have to use V71.89 for the "rule out". Some would say you could also use 786.9 which is just other signs or symptoms and would be better than using the V71.89

  3. #3
    Default chest x ray
    I would personally, not code anything without clarification. I would send it back and ask for a diagnosis. There has to be something that isn't R/O or questionable for the reason for the test.
    Just my opinion, anyone else?

  4. #4
    Default
    Quote Originally Posted by fisherd View Post
    Chest x-ray report reads rule out infiltrate. History is ? pneumonia. Conclusion states that there are no acute abnormalities. However, during this patient's stay a Chest CT and a previous chest x-ray state that the patient does have pneumonia.

    Would it be correct to use 486 for this chest x-ray performed several days later?

    Thank you.
    If the patient has a pneumonia, code pneumonia!

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