Awareness : OBC Tips

Diagnosis Based on Results of a Diagnostic Test

When a physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be billed as additional diagnoses, if they are not fully explained or related to the confirmed diagnosis.

When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury, the physician interpreting the diagnostic test should bill the reason for the test (e. g. screening) as the primary ICD-10-CM diagnosis code. The results of the test, if billed, may be recorded as additional diagnoses.