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 that led to the diagnostic test since the test did not confirm COPD or any other specific condition. In this case, the symptom is a severe cough.

A Patient Presents to the Radiology Department with an Order