tci Outpatient Facility Coding Alert - 2019 Issue Q4

Reader Question: Treat Indicative Diagnoses as Definitive Findings

Question: In the impression of the report, the provider documents that “contrast opacification of the subacromial and subdeltoid bursa is indicative of a rotator cuff tear.” Is this sufficient documentation to code a rotator cuff tear? Louisiana Subscriber Answer: There are numerous instances where the terminology behind a particular diagnosis can rule it out from being reported as a diagnosis code. The most common offenders are terms such as “probable,” “likely,” “suspected,” etc. However, if the provider documents that a particular set of findings is “indicative” of a diagnosis, then...

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