Pt comes in with symptoms of carpal tunnel syndrome. Provider notes pt complains of numbness and tingling, does exam of wrist/hand, and then gives diagnosis of CTS. In this case, do I pick up the CTS diagnosis or the signs/symptoms? Is it enough for the provider to state that it is CTS, or is a test (EMG) necessary to confirm CTS?
Similar question for pneumonia: Is a history and exam enough for the provider to diagnose pneumonia and for me to code that, or is a chest x-ray or other test necessary and I just pick up the signs/symptoms? (I had a case last week where provider diagnosed pneumonia and ordered medication, but did not order any further testing, leading me to wonder if the exam alone is enough to confirm pneumonia.
When I research the above two questions, I don't find any clear answers. I have checked ICD-9 guidelines and also don't see anything. I would appreciate any explanations or pointing me in the right direction. Thank you!
Diagnosis vs signs/symptoms for CTS and pneumonia
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