Radiology Coding Alert

Question: When documenting impressions in their reports, our radiologists will sometimes comment on incidental finding. What constitutes an incidental finding? How is it coded?

Minnesota Subscriber

Answer: An incidental finding is an observation that is not related to the original purpose of the examination. In other words, a finding is incidental if it is not related to the signs or symptoms that prompted the test to be ordered.

For instance, a chest x-ray (i.e., 71020, radiologic examination, chest, two views, frontal and lateral) is performed on an elderly patient suffering from influenza that has developed into pneumonia (487.0, influenza with pneumonia). In recording impressions from the study, the radiologist mentions that the patient has a deformity of the spine, such as scoliosis. The spinal abnormality would be considered an incidental finding.

Coders would not assign a code to this incidental finding but would code only what is related to the reason for the study.