Resolved ABNORMAL FINDINGS

[JackieL_48887]

hi all
I am getting confused and need some clarification. Do you still code the symptom if symptom is answered in report? but there was an abnormal finding?...for example initial diagnosis is back pain unspecified. Radiologist report states patient has spondylosis w/oradiculopathy but also reports an abnormal finding of masslike ecotexture. so my question is would you code M47816, R93.7, M54.50 OR would you code M47816,R93.7 and not code the back pain since it is a symptom of the spondylosis?
thanks in advance

 

[Lori]

ICD-10 Guidelines state:

Abnormal findings
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not
coded and reported unless the provider indicates their clinical significance. If the
findings are outside the normal range and the attending provider has ordered other
tests to evaluate the condition or prescribed treatment, it is appropriate to ask the
provider whether the abnormal finding should be added.

Please note: This differs from the coding practices in the outpatient setting for coding
encounters for diagnostic tests that have been interpreted by a provider.

 

[JackieL_48887]

ICD-10 Guidelines state:

Abnormal findings
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not
coded and reported unless the provider indicates their clinical significance. If the
findings are outside the normal range and the attending provider has ordered other
tests to evaluate the condition or prescribed treatment, it is appropriate to ask the
provider whether the abnormal finding should be added.

Please note: This differs from the coding practices in the outpatient setting for coding
encounters for diagnostic tests that have been interpreted by a provider.

thanks