Is it appropriate to report codes for diagnoses recorded as "evidence of cerebral atrophy" and "appears to be a nasal fracture," when documented on outpatient radiology reports?
The phrase "appears to be," listed in the diagnostic statement fit the definition of a probable or suspected condition and would not be coded in the outpatient setting. The Official Guidelines for Coding and Reporting, Section IV.I. state, â€˜Do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.' In terms of coding and reporting for hospital inpatients, according to the Official Guidelines for Coding and Reporting, Section III.B., it would not be appropriate to code abnormal findings from radiology reports.
However, when the provider documents "evidence of" a particular condition, it is not considered an uncertain diagnosis and should be appropriately coded and reported in the outpatient setting.