coding from the history portion on xrays

Networker3412

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hello,

i was taught that you can code from the history portion on the xray report since the radiologist are md that it is ok. one of my coworkers say she was taught by her teacher that you cannot not even for medical necessity purposes. i also have research this on the american academy of radiology assoication that states that at the time of the xray that if the radiology dept cannot get a dx from the ordering physician they can what the pt says. can someone answer this and provide me a link or documentation.

also my director says on er's that if a physician checks marks the box that says nursing assessment reviewed that we can take dx from the nursing record.i was not taught that way any thoughts from anyone on here as i have used other sights, talked with several teachers who also give different answers.

thanks
 

mitchellde

True Blue
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AB-01-144 is a very informative transmittal for this.. here is an excerpt:
On the rare occasion when the interpreting physician does not have diagnostic information asto the reason for the test and the referring physician is unavailable to provide such information,it is appropriate to obtain the information directly from the patient or the patient’s medicalrecord if it is available. However, an attempt should be made to confirm any informationobtained from the patient by contacting the referring physician.
 
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