Wiki DIAGNOSIS - UNSUPPORTED BY MRI

[PaigeMatthews]

Can a doctor diagnosis a meniscus tear without an MRI to back it up?

 

[thomas7331]

Can a doctor diagnosis a meniscus tear without an MRI to back it up?

That's a question to ask the doctor - from a coding perspective, the diagnosis is whatever the provider says it is. The only exception that I know of in the coding guidelines is specific to the neoplasm codes, which do require a pathology report.

 

[csperoni]

@thomas7331 took the words out of my mouth. The coder's responsibility is to assign the CPT/ICD10/modifiers, etc. To simply translate the words into codes. I would not question the clinical judgment of a provider.
Don't forget for pro fee claims, if the provider states possible, probable, suspected, etc, then you do not code that condition but rather the signs/symptoms.
If the provider writes "likely meniscus tear", you code the signs/symptoms - pain, swelling - whatever is in the record.
If the provider writes "meniscus tear", you code the meniscus tear.