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Standards Section 6
Equal Importance, Specificity, Diagnositc Test Results
Question | Answer |
---|---|
When two or more diagnoses of equal importance are listed with no clear indication in the health record as to which one is the MRDx/main problem, what should the coder use? | select the condition for which a surgical or non-surgical procedure (not diagnostic) was performed. If no surgery was performed, select the first-listed diagnosis as the MRDx/main problem. |
When one diagnosis describes a condition in general terms but a more descriptive term providing more precise information about the site or nature of the condition is reported for another listed diagnoses, the coder should? | select the most specific condition |
Use X-ray, pathology and other diagnostic results (excluding laboratory reports) when they clearly add | specificity in identifying the appropriate diagnosis code for conditions documented in the physician/primary care provider notes. |
Laboratory reports are not used to add specificity to a documented condition. | There must be physician documentation confirming the results from the laboratory report. |
When a condition is suggested by diagnostic test results, assign a code only when the condition has been confirmed by | physician/primary care provider documentation. |
In ICD-10-CA, the dagger symbol (†) is used to indicate a code that represents the | etiology (cause) or underlying cause of a disease. |
The asterisk symbol (*) is used to indicate a code that represents the | manifestation (symptom) of a disease. |