Health Information Management

Q&A: Code or query for clinical significance?

CDI Strategies, March 15, 2012

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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?
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 they most likely do not 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 about coding these or not and consider querying the physician to either confirm or rule out.

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.

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