vendredi 1 mai 2015

Coding ICD-9 of Echocardiogram reports ?

Hello,

My question is, am I a certified coder able to code diagnosis of the Echocardiogram Conclusion report?

This is what I found in Coding clinic and my interpretation is that we can't. That we must wait until the physician confirms the diagnosis in a progress note. These are performed in a office setting and not inpatient setting.

Coders are not allowed to assign codes directly from impressions included on diagnostic reports, such as x-rays, MRI, CT scans, electrocardiograms, echocardiograms, and pathology, even if a physician has signed the diagnostic report. The diagnosis must be confirmed by the physician in the body of the medical record (eg, progress notes or discharge summary) before it can be coded. However, if the diagnostic report is adding specificity to an already-confirmed (physician-documented) diagnosis, then the coder may use the more specific code based on the diagnostic report without obtaining physician confirmation (AHA Coding Clinic for ICD-9-CM, 1999, first quarter, page 5).

Thank you!



Coding ICD-9 of Echocardiogram reports ?

Aucun commentaire:

Enregistrer un commentaire