Sometimes the physician will document differential diagnosis [DDx] and list a number of diagnoses that he or she may be considering, depending on the presenting complaint, the patient's signs and symptoms and based on the initial clinical assessment. For example, the patient presents with sore throat and the physician documents DDx followed by: esophagitis pharyngitis Streptococcal throat A code is assigned for the confirmed diagnosis. Specific diagnostic test results [e.g., diagnostic imaging reports -because these are read and interpreted by a radiologist, who is a medical doctor; or pathology reports -because a pathologist is a medical doctor who is trained and qualified to evaluate tissues and cells using special equipment, tools and (chemical) substances to establish a diagnosis] may be used to specifically classify a diagnosis documented by the primary healthcare provider. For example, the primary healthcare provider documents that the patient has a breast lump; a biopsy is performed. The pathology results come back malignant. Therefore, the lump is specifically classified to a code from category C50. Malignant neoplasm of breast; or the primary healthcare provider documents that the patient has a fractured leg; an X-ray is ordered. The X-ray results come back "fracture shaft of tibia ... Therefore, the fracture is specifically classified to S82.200 Fracture of shaft of tibia with or without fibula, closed. 101 © HealthCareCAN All rights reserved ALGONQU!~~ COLLEGE
'!11 rearning ., a division of •61"" HeallhCareCAH Key Activity Review the Canadian Coding Standards for JCD-10-CA and CCI, General Coding Standards for ICD-10-CA, "Using Diagnostic Test Results in Coding ... Laboratory results [e g., complete blood count [CBC]. chemistry, culture and sensitivity] on the other hand, must be interpreted by the primary healthcare provider to establish a diagnosis. For example, the primary healthcare provider documents that the patient has a urinary tract infection [UTI]; a urine culture and sensitivity [C&S] is ordered. The laboratory results come back "urine positive for Escherichia coli [E coli]. sensitive to fluoroquinolone." The code for the causative organism is only assigned, optionally, when the primary healthcare provider documents that he or she agrees the causative organism of the UTI is, in fact, E.coli. In summary, the coder m ust enter or verify all administrative and demographic data, complete all mandatory data elements and assign and enter the ICD-10-CA code[s] for the significant diagnoses, apply problem type and assign and enter the CCI code[s] for the mandatory interventions, after all the pertinent primary healthcare provider's notes, all the nurses· notes and all procedure notes, et cetera, have been reviewed.
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