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Wiki Coding from Radiology/Pathology Report

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KoBee

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In outpatient coding (office setting), seems like there has been some back and forth, are coders are allowed to code from the pathology and radiology reports for specificity of a diagnosis?

Patient comes in for shortness of breath and cough, provider orders Xray, patient has pneumonia per radiology results/report. Should this consist of a query for provider to addend report to reflect pneumonia? before claim is sent to billing?
 
Hi KoBee
Yes you can code from results of the radiologist conclusions to get specific dx. If the results show no abnormalities, then use the reason why referred for an xray....pain, dx M25 or M79 blocks, R07.89 chest pain, stomach gas K29, Etc.
Lady T:)🦴(y)
 
CPT CODE CHANGING -Outpaitent Radiology -If a pt presents for Barium Enema (74280), pt given gown ,technique & procedure is explained, then scout image is preformed, which shows pt is not preped properly and exam is stopped. Can a abdomen xray (74018( be billed rather than failed/cx exam 74280 with modifer 52?
 
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CPT Change -Outpatient Radiology- Pt presents for US Core Biopsy (19083) pt gowned, pocdure,technique explained. US is done to locate area of intrest and is not identified. Procedure is stopped. Can the US(77641) be billed rather than failed/cancelled biopsy (19083 w/mod -53)?
 
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