When coding diagnostics, if the test is positive, what should the coder report?

In the context of coding diagnostics, when a test yields a positive result, the coder should report the findings from the test. This is essential because the findings directly reflect the outcome of the diagnostic procedure and provide the necessary clinical data for medical decision-making and treatment plans. Reporting the findings allows for accurate coding that aligns with the specific conditions or diseases indicated by the positive result.

Additionally, it provides a clear and documented basis for justifying the medical necessity of tests and subsequent treatments. By focusing on the findings, the coding process ensures that the information captured is relevant and actionable, fostering better healthcare outcomes.

While considerations like the indication for the test and the physician's interpretation are essential aspects of the overall clinical scenario, the crux of what needs to be reported in coding diagnostics is the tangible result or finding from the test itself, which carries the most significance in clinical documentation. Therefore, when a test is positive, the primary focus should be on conveying those diagnostic findings clearly.