When may a facility coder appropriately abstract a diagnosis from a pathology or radiology report during inpatient coding?
Select an answer to reveal the explanation.
Short Explanation
Path and rad reports are part of the clinical story, but you do not vacuum every incidental line into a code. Guidelines tell you when those findings are fair game. If the rules say you can use them and the finding meets reporting criteria, abstract it; otherwise leave it alone.
Full Explanation
Pathology and radiology reports can contribute findings the attending may use, and Official Guidelines for Coding and Reporting specify when diagnoses may be coded from diagnostic reports. Coders abstract reportable findings only when those guideline conditions and documentation standards are met. Inventing codes from charge text or assuming every ancillary mention is reportable is incorrect.