Q&A: Code or query for clinical significance

Q: I am wondering about whether coders can use information the physician takes from test results and includes in the history and physical (H&P). We recently had a situation where the H&P indicated under the studies section that “chest x-ray showed atelectasis,” or “EKG showed right bundle branch block (RBBB) with anterior fascicular block” etc.

Some of us believe that it’s okay to code the diagnosis, i.e., atelectasis, if the provider states that the testing “showed” the diagnosis. Others believe we 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 argued 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 makes it okay to code from this information.  I realize you cannot go to the testing result itself and code from it directly. What are your thoughts?

A: Most of the time these kinds of findings are “incidental,” in other words, they may have no clinical significance. I think it’s important to investigate whether these “new” findings lead to additional interventions, medications, more workup, etc.  If not, then I don’t feel they meet criteria for coding/reporting. Just because something is mentioned does not mean we should code it.  If I review the record and don’t see a direct correlation between a documented diagnosis and orders for care, I query for the clinical significance of the diagnosis.

We are seeing more and more copying and pasting of diagnostic findings from diagnostic reports into physician notes with no further documentation of clinical significance, treatment plan, etc. So you must be very cautious on coding these or not. Be sure to query the physician to either confirm or rule out the findings.

Editor’s Note: This question was answered by Lynne Spryszak, RN, CPC, CCDS, and Sue Belley, M.Ed., RHIA, CPHQ, of the ACDIS Advisory Board following the February 16 ACDIS Quarterly Conference Call.