Wiki coderem

[thomsene]

Hi
Anyone know of a Radiology resource that has coding guidelines for where the primary dx is
taken from when you have confliciting information from the physician order reason for visit and the clinical indication/history from the radiologist dictating the findings in a outpatient Hospital setting.
coderem

 

[cblack712]

You need to talk to the Radiologist to see why it was changed. This could be a simple error on their part - they could have seen the wrong order...etc. Then again the radiologist or tech could have had a discussion with the patient in which they were told of other signs and symptoms. The only guidelines that I can think of is in the front of the ICD-9 book (coding guidelines - pg29) that indicates that for diagnostic studies the 1st listed dx should be the reason that the patient was sent.