If we suspect a certain diagnosis for a patient seen in our office, such as Chiari malformation type 1, but are not positive of this until we receive the test results, should we report the evaluation and management (E/M) service using code 348.4 (compression of brain)?
According to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) reporting guidelines for outpatient services (eg, physician office), probable, suspected, questionable, or rule-out conditions should not be reported. Once the test results confirm the diagnosis, it may be reported. The medical record documentation should reflect the suspected diagnosis or condition. However, the reported code should be the symptoms, signs, abnormal results, or other reason for the encounter.
What diagnosis code should be used to report alpha-1 antitrypsin deficiency?
Code 273.4 is used to report alpha-1 antitrypsin deficiency.
How do we report testosterone and Solu-Medrol when administered by intramuscular (IM) injection?