I am having a discrepancy with some of my rads and ortho doctors (that read their own films). I know that they are suppose to have the indication, number of views, body and then impression. Myself as a coder can I code off the body for example. An abdominal series: Indication: abdominal pain.
Body states pt has a small renal cyst and small ovarian cyst. But his
impression states: normal. If the rad, doesn't want to do any correction can I code the renal cyst & ovarian cyst. Or do I just code off the impression which states normal thus I would code the abdominal pain. Hope this isn't confusing. I have found some info in Radiology Management about coding but it doesn't specifically state that a coder is suppose to just code off impression or reason for study. If there is a formal guideline out there could you let me know where to find it
thanks, Marsha
Body states pt has a small renal cyst and small ovarian cyst. But his
impression states: normal. If the rad, doesn't want to do any correction can I code the renal cyst & ovarian cyst. Or do I just code off the impression which states normal thus I would code the abdominal pain. Hope this isn't confusing. I have found some info in Radiology Management about coding but it doesn't specifically state that a coder is suppose to just code off impression or reason for study. If there is a formal guideline out there could you let me know where to find it
thanks, Marsha