Wiki coding from radiology reports in ED

[NIKI01]

Hello,
I was wondering if someone could let me know when to code from radiology reports in ED.
In this case, patient came in after Fall with hand injury. X-ray was ordered for the right hand to rule out any acute fx. The final dx was "skin tear of rihgt hand wihtout complications, initial encounter." the ED Physician did not document the results of the x-ray. I reviewed x-ray report and a radiologist documented "diffuse osteopenia."
My question is--can the "diffuse osteopenia" be coded from the radiology report without an ED Provider result interpretation documented in the ED Provider Notes?
Can a coder code directly from the CT, MRI, X-ray report when the ED Provider ordered these tests without documenting his/her interpretation/results in the notes?

Thank you so much for your help,

 

[Sarah Ann]

The treating provider is the only source I use. Yes the radiologist is a physician, but they are not treating the physician. The ER provider diagnoses a fracture, the radiologist does not see one. I code the fracture- because that is what the examining provider is stating the dx on that DOS during the encounter. There are coding clinics that address incidental findings on rad. reports. That could be just me though.

 

[TThivierge]

Hi Nikio
When code radiology reports use the symptoms or reason why need xray or CT report. However if radiologist physician has given dx I add it on claim as medical necessity. You can code the results from the radiologist report...he is a physician too. Incidentals abnormal findings on x ray you can use the abnormal results of imaging in dx block of R91- R93.
Well hope I helped you
Lady T

 

[NIKI01]

Thank you so much for all your help