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Wiki E/M Diagnosis question

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Dug94Jen

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Local Chapter Officer
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Burlington, Vermont
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My question is when I have a progess note and there is no clear diagnosis given by the doctor, however there are results listed in the x-ray/MRI taken can I use the information from the x-ray/MRI. I been told no we can't and I've also been told that we can. HELP which one is it.
 
Was the MRI and xray performed on the same day as the physician encounter? If so then yes you may use the dx indicated by the radiologists as he is a physician. If not then no you cannot, you can use the signs and symptoms documented.
 
Mitchellde - thank you so much for your quick response to my question. If you are able, would mind telling me where I can find the documentation to support that I can code from the x-ray that would be great. If you read me earlier response, I hope I didn't offend you. After I sent the earlier message, I realized that it sounded rude.
So, again my apologies
 
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It would be always better if the visit attending confirms the x-ray finding (radiologist's) to report the diagnosis.
 
I found it stated in the coding guidelines from several years back, you can utilize diagnosis rendered by physicians and a radiologist is a physician.
 
While coding office visits, I observed many times that visit attending contradicting radiologist's opinion.
 
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