A patient presents to the radiology department with an order for a CT scan. The provider's diagnostic statement supporting the scan is "severe cough, probable COPD." Upon examination, the CT scan does not show evidence of abnormality with the lungs and surrounding structures. How should the coder appropriately code this patient's diagnosis?

Question

Quizplus · Accepted Answer

The appropriate coding in this scenario is to code for the symptom that led to the diagnostic test, which is the severe cough, since the CT scan did not confirm COPD or any other abnormality.

A Patient Presents to the Radiology Department with an Order