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Coding Signs, Symptoms, and Abnormal Tests
Patient's symptoms were: Rt upper abdominal and epigastric pain and nausea.
No confirmed diagnosis, assessment mentions.... Patient is noted to have abnormal liver chemistries with resultant jaundice. An abnormal CT scan and an abnormal HIDA scans. Rule out primary biliary cirrhosis.
Would I code:
Right upper abdominal pain
epigastric pain
nausea
abnormal liver test
abnormal CT scan
abnormal HIDA scan
jaundice
Thanks I get so confused about coding abnormal tests.
Depends
what are you coding? What was known at the time of the visit? IS this one visit or multiple visits to follow up on tests?
Coding Signs, Symptoms, and Abnormal Tests
Thanks for the reply.
What are you coding? An inpatient consultation-initial visit.
What was known at the time of the visit? Just the symptoms of RT upper abdominal pain, epigastric pain and nausea. elevated liver enzymes and abnormal CT scan of abdomen. The physician ordered further tests.
IS this one visit or multiple visits to follow up on tests? Physician will follow up after further tests.
Since there is no confirmed diagnosis and the physician mentions the abnormal test results in the assessment, is it correct to code: RT upper abdominal pain, epigastric pain, nausea, abnormal liver chemistries and abnormal CT scan of abdomen?
Thanks