In outpatient coding, coders are allowed to code from the pathology and radiology reports without the attending/treating physician confirming the diagnosis. If there is a final report available at the time of coding, which is authenticated by a physician, it may be used to code from.

The Annual Routine Physical Exam can be documented using codes 99385-99387 for new patients and codes 99395-99397 for established patients.

‘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.

A possible, probable, suspected, likely, questionable, or still to be ruled out condition can be coded if still documented as such at the time of discharge. Other similar terms used to describe possible conditions could include consistent with, compatible with, indicative of, suggestive of, and comparable with.

by Coding Info on February 21, 2018 in CPC Exam tips – Radiology coding Guidelines. Radiology is a division of science that using imaging techniques like x-ray, Ultrasound, MRI/MRA, CT/CTA scan and PET scans to diagnose and treat a health condition.

An incidental finding is something extra found by the test. It’s something not related to the reason your doctor ordered the test. For example, a doctor may order a CT scan of your chest to look for a blood clot. There may or may not be a blood clot, but the picture also shows a small growth in your lung.

CPT code 99211 (established patient, level 1) will remain as a reportable service. History and examination will be removed as key components for selecting the level of E&M service. Currently, history and exam are two of the three components used to select the appropriate E&M service.

What If the Patient Isn’t Present? If the patient’s children or spouse present to the practice to discuss the patient’s condition with the doctor and the patient is not present, you cannot bill Medicare using the E/M codes. “CMS states that the patient has to be present,” says Coding Consultant Donelle Holle, RN.

If they pick the wrong code yes you can change it.

In the inpatient setting, coders are not allowed to assign codes from diagnoses listed on diagnostic reports such as radiology, pathology, and echocardiogram (ECHO) even if a physician has signed the diagnostic report. An ECHO is not a routine diagnostic study performed on every patient.

Code First/Use Additional Code The ICD-10-CM coding convention requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists there is a “Use Additional Code” note at the etiology code, and a “Code First” note at the manifestation code.

diagnosis
The first thing the coder must do in the coding process is locate the diagnosis in the patient’s medical record.

The Coding Guidelines are a set of rules that complement the official instructions within the ICD-9-CM manual. Often times, a medical coder gets stuck with a particular case and is unsure what direction to take in order to accurately describe a patient’s encounter. The Coding Guidelines are designed to give additional instruction per section.

Diagnosis that were treated and resolved in the same encounter should be coded. If the patient came in with a history of a condition that was resolved prior to the encounter then it should not be coded unless it has an impact in the present treatment of the patient.

In outpatient coding, coders are allowed to code from the pathology and radiology reports without the attending/treating physician confirming the diagnosis. The pathologist and radiologist are physicians and as long as they have interpreted the tissue or test then it may be coded.