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mcdream

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Hi all!
If the provider's E&M note references a diagnosis from a radiologic procedure but doesn't specify site &/or laterality in his E&M note, can a coder review the radiology report in the MR in order to code to the highest specificity (site/laterality) or MUST the E&M documentation stand-alone resulting in coding as "unspecified"?
Example:
E&M note states: osteopenia (M85.80 unspecified code)
Radiology report states: osteopenia of the right hip (M85.851)
TIA for your guidance!
 
As long as you are coding for outpatient and the radiology report is referenced by the physiian then you can use the report for a more specific dx.
 
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