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Wiki coding from radiology interpretation

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MnTwins29

MnTwins29

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I would agree that coding the reason for the encoutner as the admitting dx, but as far as coding every diagnosis listed, that may not be necessary. If the physician believes it is significant, I would code it and also if it is is a condition in which the admitting dx is a sign or symptom.

Using your example of a spinal MRI, if the two diagnoses listed are the two you described, DDD and a herniated disk, I would code both of them, especially if the admitting dx was "back pain". If something not related to the back pain is also mentioned by the doctor it isn't wrong to code it.
 
I would have coded the HNP and the DDD only. Coding the reason for the exam is not necessary when there is a definative dx available for an outpatient center.
 
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