Q&A: Code or query for clinical significance?
Q: We are having a discussion about how to code when the history and physical (H&P), under the studies section, indicates that the chest x-ray showed atelectasis or that an electrocardiogram showed right bundle branch blockand with anterior fascicular block. Some of us believe that it’s ok to code the diagnosis, i.e., atelectasis, if the provider states that the testing “showed” the diagnosis, whereas others believe you cannot code the diagnosis as this is a lab/testing result and the provider could just be reading the results onto their H&P dictation.
However, I argue that since the provider is using this information to make decisions about care/testing/procedures and indicates the testing results in the H&P body, that it would be okay to code for it. I realize you cannot go to the testing result itself and code from it directly. What are your thoughts?
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