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 correct approach is to code for the symptoms (severe cough) that led to the diagnostic test since the CT scan did not confirm COPD or any other abnormalities. Coding guidelines recommend coding the reason for the encounter when a definitive diagnosis has not been established.

A Patient Presents to the Radiology Department with an Order