Can you code from a radiology report in the E.D. setting??

meleah80

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I thought the answer was yes, but I am not finding any documentation that specifically states that in the Emergency Department it is okay. Can anyone provide me with a link to this?

Thanks,
Meleah
 

mitchellde

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As long as you are not coding inpatient facility, then yes for outpatint or physician you may code findings from the radiology report. Check the gudelines for coding and reporting as posted on the CDC website for this information.
 
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I thought the answer was yes, but I am not finding any documentation that specifically states that in the Emergency Department it is okay. Can anyone provide me with a link to this?

Thanks,
Meleah
Yes you can in a ER setting. Either as secondary findings or you can use the rpt as a better detail of an primary dx- i.e. fracture sites.
You should be able to find these guidelines in your coding clinic.
 

Lizz B

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radiology coding, ED dept.

I'm a little confused on this. If the final dx by the ED doctor is 'knee pain', and the radiology report notes 'evidence of degenerative changes and joint effusion', would you code only the DJD and effusion since pain is a symptom or would you code the pain as the PDX and the DJD and effusion as secondary dx? I realized the radiologist is a physician and his dx are codable, just finding it confusing.
Thoughts anyone? I've read numerous articles, regulations, coding clinic, etc, and understand why you would code the dx for outpatient diagnostic services, just confused on the ED encounters.
Thanks in advance for your input.:confused:
 

sswisher

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Code the pain. The radiologist is looking at the image but the ED doc is looking at the patient. The pain might be from a ligament injury or meniscus tear, and the DJD with effusion may or may not actually be relevant. In other words, just because something is on an xray doesn't always mean it's what's causing a symptom.
 
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