Radiology Coding Alert

Question: I learned that I can choose my diagnosis code off of the physician's order, and if that doesn't offer a valid ICD-9 code, then I can code off of the radiologist's report. But how should I code if I don't see a valid reason for the exam documented and the report is negative?

Arizona Subscriber


Answer: You should actually look at both the radiologist's report and the physician's order before deciding what diagnosis to code.

If the referring physician's order lists symptoms, and the radiologist's interpretation identifies the symptoms' reason, then code the radiologist's diagnosis. If the exam results are nondiagnostic, then code the signs and symptoms that prompted the test.

Mistake: Don't code conditions that are unconfirmed, regardless of whether the referring physician or radiologist documents them. Official ICD-9 guidelines instruct you not to code suspected diagnoses or diagnoses the doctor is trying to rule out for outpatients (www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm, page 89).

Example: You have an order from a physician who suspects fracture in a patient complaining of lower right arm pain. The x-ray (73090, Radiologic examination; forearm, two views) does not show a fracture or reveal any other problem. Reporting 813.40 (Fracture of radius and ulna; lower end, closed; lower end of forearm, unspecified) based on the order would be incorrect. Instead, you should report the symptom that prompted the test, 729.5 (Pain in limb).

Pitfall: Don't report an incidental finding -- an abnormality the radiologist identifies during the exam unrelated to the exam's reason -- as the first-listed diagnosis code.

Example: You get a chest x-ray order: "Cough, rule out pneumonia." The radiologist states there is no active disease in the lungs but there is evidence of arthritis in the thoracic spine. The arthritis is an incidental finding. Code the cough as the primary diagnosis. You can report the arthritis as a secondary diagnosis if desired.