tci Outpatient Facility Coding Alert - 2019 Issue 6

Reader Question: Take Indication, Impression into Account When Choosing Dx

Question: I’m working on a chest X-ray with an indicating diagnosis of chest pain and cardiomegaly documented in the impression. Should I code this as cardiomegaly? Nevada Subscriber Answer: If there are no other indicating diagnoses referenced outside of chest pain to refer to, you should not report code I51.7 (Cardiomegaly) as your primary or secondary diagnosis. That’s because you would be making a questionable assumption that the cardiomegaly is, in fact, related to the chest pain. Many patients with cardiomegaly are asymptomatic, and without any other underlying cardiovascular conditions to consider, you’d be taking...

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