Radiology Coding Alert

Wrap your head around incidental findings with this guide.

In regards to most medical specialties, radiology stands on its own for a variety of different reasons. When it comes to interpreting imaging scans, providers have a responsibility to report any and all conditions that present themselves, whether they are necessarily related to the underlying reason for the encounter or not. It's the coder's responsibility to sift and differentiate between those diagnoses that are and are not related to the patient's reason for the imaging.

When the provider documents conditions and diagnoses that are not related to the underlying reason for the visit, the coder must know when not to include these diagnoses on the patient's claim. These diagnoses, also referred to as incidental findings, are not considered pertinent to the patient's chief presenting reason for the scan. However, making the decision of when and how to omit these incidental findings from the final claim is not an exact science.

Take a look at these tips and a real-world example to help steer you through scenarios in which you should and should not report the incidental findings.

Don't Be Discouraged by the Lack of Incidental Findings Guidelines

Explaining when and where to omit the incidentals from a report would be a lot easier if there were definitive guidelines in place to state one way or another. Unfortunately, neither the ICD-10-CM nor the Centers for Medicare and Medicaid Services (CMS) have any specific set of rules in place.

With that in mind, there are a few disclaimers that need to be addressed before jumping into a clinical scenario involving incidental findings.

Disclaimer 1: Incidental findings are subjective, by nature. This means that one person may interpret a set of findings as incidental, while another may have a slightly different view of the situation.

Disclaimer 2: There are no guidelines prohibiting coders from submitting findings that are clearly incidental to the patient's reason for the visit. The "general" coding suggestion is to omit any finding that is not pertinent to the study, but sometimes identifying the incidental finding isn't as clear-cut as one might think.

Example: Patient receives a computed tomography (CT) abdomen w/o contrast. The indicating diagnosis reads "right upper abdominal pain. Possible gallstones." In the impression, the physician documents "no acute findings indicating gallstones. However, biliary sludge is noted. Additionally, a small left kidney cyst and fatty liver are present."

"In examples such as this, it's pertinent that the coder has a strong fundamental understanding of the anatomy involved," says Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. "Since the physician performs the ultrasound for the diagnosis of right, upper abdominal pain, you can conclude that a left kidney cyst is not a culprit of the patient's pain - exclusively for reasons of proximity, alone."

Next, you should take a look at whether or not fatty liver is a worthwhile diagnosis to include on this patient's claim. Unless the provider states any additional, extraordinary information, it's safe to conclude that this is merely an incidental, unrelated diagnosis.

However, when it comes to evaluating the patient's diagnosis of biliary sludge, your understanding of the anatomy at hand comes back into play. While biliary sludge and gallstones are two distinct diagnoses, biliary sludge and gallbladder sludge can often precede the formation of calculus of the biliary tract and gallbladder. Sludge in the biliary tract and gallbladder can also be a source of pain, among other symptoms.

Therefore, you should not make the mistake of considering biliary sludge an incidental diagnosis. In fact, it's a rather significant finding, and is worthy of being submitted as the primary diagnosis for code 74150 (Computed tomography, abdomen; without contrast material). You will code biliary sludge under code K83.8 (Other specified diseases of biliary tract).

Abide by Your Practice's Guidelines, Severity of Condition

Ultimately, whether or not you decide to include the kidney cyst and fatty liver diagnoses on the final claim is up to you and your practice manager. "Coders should consider their internal practice policies, Merit-based Incentive Payment System (MIPS) quality measure guidelines, and the severity of the findings when determining whether to code an incidental finding," explains Amanda Corney, MBA, medical billing operations manager for Medical Resources Management in Rochester, New York.

Corney offers valuable advice to coders having trouble making the distinction between incidental findings and those of clinical significance. In respect to clinical significance, the finding can either be significant as it relates to the reason for the visit, or significant in the context of the patient's overall health.

For example, if the provider suggests follow-up imaging on a particular diagnosis that would, under other circumstances, be considered incidental, then you should include the finding as a secondary diagnosis. Even if the provider does not suggest follow-up imaging, the severity of the condition may justify its addition as a secondary diagnosis code. Lastly, make sure to include a diagnosis that is necessary for the reporting of any MIPS measure, regardless of if it may be incidental to the reason for the visit.