Coding Abnormal Findings

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PostVabel on 16/4/2013, 9:58 am

We are a portable x ray and lab servicing nursing homes. Our documentation is limited to a copy of the requisition slip and a physician's order. If the diagnosis provided is not within the National Coverage Determination i.e. CEA (82378) test is ordered and the diagnosis written on the requisition is V58.69. The lab test was resulted with a high CEA. The diagnosis we coded is for 795.81 (elevated CEA). Are we as coders can code this abnormal findings per coding guidelines for outpatient without confirming the physicians?

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