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Wiki ct mri interpretation

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lbriley

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Here's the deal. I am a coder for a neurology practice. The CT and MRI interpretations have me a little befuddled. The documentation I receive states the reason for the exam such as: closed head injury, loc, seizures, etc. Then on the interpretation sheet the doctor goes into everything they find on the exam, such as, ischemia, atrophy, white matter hyperintensities etc. Then will state it as a positive exam. Shouldn't I just code the reason for the exam since the other things are incidental (excluding a bleed or infarct) and if the reason for the exam is a result of an injury do I use an E code. HELP!!
 
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