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.
Editor’s Note: This question was answered by Lynne Spryszak, RN, CCDS, CPC, an independent HIM Consultant in Roselle, IL, and Sue Belley M.Ed., RHIA, CPHQ, Project Manager, 3M HIS Consulting Services, in Atlanta, GA. These members of the ACDIS Advisory Board responded to this question following the February 16 ACDIS Quarterly Conference Call.