Resolved Mild urinary bladder wall thickening

[LeaG_12642]

I code imaging study diagnoses. the CPT codes are already put in and I just code the diagnosis. I code the RVF as the diagnoses listed on the orders and then any positive findings on the studies.

I have a CT of the abdomen and pelvis and under impression, it lists mild urinary bladder wall thickening. This is a finding, not a diagnosis, correct? Therefore, there wouldn't be a code for it. I was told if 3M does not lead you to a code, then there is no code, and this is true for mild urinary bladder wall thickening. However, would this be considered an abnormal finding, and if so, would I code R935 for abnormal findings on diagnostic imaging........ ?

 

[Lori]

ICD-10 guideline for -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.