Wiki Diagnosis coding Radiology

[wjones3b]

If there is no reason for the Xray in the clinical information and the Xray is normal, am I able to use a pain code or do I need to research visit in order to get a reason the Xray was done. The only dx listed is W19.XXXA, unspecified fall, which cannot be used as primary.

 

[TThivierge]

WJones3b,
You are correct cannot use dx W19 as first dx. But pain in which spot of the body? M54 low back, or M54.2 neck , or stomach R10, or leg M79. Etc? Hopefully you can read the documentation of xray or the visit from EMR or clinic. Also when incident code use..payers like WHERE it happened and DATE it happened too. Home or Street or Bathroom see dx block Y92.
I hope all data is provided for you so can document accurately
Lady T

 

[chembree]

When fall or MVA is all that is documented, you may consider Z04.3 or Z04.1.