Radiology Coding/Billing Question

[wverret]

I have a question about coding outpatient Radiology claims.

Scenario:
Little Johnny is outside playing he falls off money bars and hurts his ankle. Mother takes Johnny to local ER. ER physician thinks Johnny may have broken his ankle. ER physician does an appropriate exam, hystory and orders an x-ray of Johnny's left ankle. ER doc writes order for Left Ankle X-ray. (writes order just like I wrote it) (order is just written that simple with no indication of the number of views)

Off Johnny goes to the radiology lab.

The x-ray tech gets the order, does the films (takes 3 views) and leaves them for the radiologist to interpret. The radiologist reads the x-rays and gives his report.

Now here's where I need clarification.

The coder gets all the notes and gets ready to code the encounter. The coder list the code for the ER visit. Then how does the coder code for the x-ray. Do they code off the ER doc's order for an ankle x-ray???.....or do they code off the OP report prepared by the radiologist?

my two choices of codes are 73600 and 73610.

My position is I believe that the coder should code 73600 based on the order by the requesting physician. Other people think you would code what was actually done (76310). As an auditor I think the claim should be downcoded to 73600 because the radiologist did more than was requested.

I just want to know what is correct coding guidelines.
Willie

[slc112071]

I worked in radiology coding for seven years. I would have billed this as 73600. The ordering physician did not document the number of views, so it should be billed as the minimum.