What should a coder do if a diagnostic test is interpreted as normal?

When a diagnostic test is interpreted as normal, the appropriate action for a coder is to code the condition, symptom(s), or sign(s) that necessitated the diagnostic study. This approach helps to maintain a comprehensive record of the patient's health status and the clinical reasoning behind conducting the test in the first place. Coding the underlying condition or symptoms provides insight into the patient’s situation and ensures that relevant medical information is captured for future reference.

In medical coding, the primary focus is on accurately reflecting the patient's diagnosis and clinical interactions. When a test is normal, it does not negate the existence of the symptoms or conditions that prompted the test, and these should still be recorded. This assists in continuity of care and may influence future treatment decisions.

The consideration to not code anything or to code related signs or symptoms does not provide the necessary context regarding the patient's condition. Similarly, coding findings as positive when the test is normal would lead to inaccurate documentation and could misrepresent the patient's clinical picture. Therefore, coding the initial condition, symptom, or sign justifies the rationale for the diagnostic study while accurately reflecting the patient's health profile.