The physician interpreting the diagnostic test may report unrelated and coexisting conditions/diagnoses as additional diagnoses.
Example: A patient is referred to a radiologist for a chest X-ray because of a cough. The result of the chest X-ray indicates the patient has pneumonia. During the performance of the diagnostic test, it was determined that the patient has hypertension and diabetes mellitus. The interpreting physician reports a primary diagnosis of pneumonia. The interpreting physician may report the hypertension and diabetes mellitus as secondary diagnoses.
Diagnostic Tests Ordered in the Absence of Signs and/or Symptoms (e.g., Screening Tests)
When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury, the testing facility or the physician interpreting the diagnostic test should report the screening code as the primary diagnosis code. Any condition discovered during the screening should be reported as a secondary diagnosis.
