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

CThe correct approach is to code both the symptom (severe cough) and the condition (COPD) that was suspected or probable at the time of the CT scan order. Even though the CT scan did not show evidence of COPD, the diagnostic statement included it as a probable diagnosis, and it should be coded along with the symptom presented.

A Patient Presents to the Radiology Department with an Order