Health Information Management

Q&A: Coding for a chest x-ray showing atelectasis

HIM-HIPAA Insider, June 12, 2012

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A: These findings are generally incidental and may have no clinical significance. Investigating whether these new findings lead to additional interventions, medications, or more workup is important. If not, they most likely do not meet criteria for coding or reporting.

The mere mention of something doesn’t mean it should be coded. If I review a 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.
 
Copying and pasting diagnostic findings from diagnostic reports into physician notes with no further documentation of clinical significance or treatment plan is occurring more frequently. Be very cautious about coding this information, and consider querying physicians to either confirm or rule out.
 
Editor’s note: Lynne Spryszak, RN, CCDS, CPC, an independent HIM consultant in Roselle, Ill., and Sue Belley, M.Ed., RHIA,CPHQ, project manager at 3M HIS Consulting Services in Atlanta answered this question, which originally appeared in the March issue of CDI Strategies.



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