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thomsene

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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
 
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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.
 
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