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Admissions based on abnormal CT without any symptoms

Author: Preview Account Views: 2646 Created: 2010-11-16 06:37 Last Updated: 2010-11-18 10:31

The reason of the admision was the abnormal CT angiogram (no other syptoms).
As a principal diagnosis I choose R93.1.Is that correct?

HIO Answer:

Yes, the right code is R93.1 "Abnormal findings on diagnostic imaging of heart and coronary circulation"

It is expected that there should have been at least a symptom for the CT which could be coded. If there really has not been a symptom which can be described, the symptom "abnormal findings" is ok.  However, in case of no other symptoms, one could ask why a CT had been performed?

The hierachy in the decision for principal diagnosis is:

  1. confirmed diagnosis
  2. diagnosis not confirmed but for clinical reasons treated like confirmed
  3. symptom (like specified pain, R-Code)
  4. symptoms like abnormal findings (R-Code)
  5. obersvation for suspected disease (Z-Code)