Wiki Help with Radiology coding with different header

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kschoenberger

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When coding a radiology report, it is my understanding that ultimately a coder should be coding from what is actually dictated in the report.

For example, if the title says CT w/o Contrast, but the radiologist has clearly dictated that the procedure was performed with and w/o contrast, it can be coded as with and w/o. Is this correct?
 
Ask the doctor

I work with surgeons, not radiologists, but ...

We code from the body of the report, not from the heading / title.
However, if there is a discrepancy from the heading to the body of the note, I go back to the physician and ask for clarification. Sometimes it's a transcription error.

F Tessa Bartels, CPC, CPC-E/M
 
I would not go by the header only, read the report, see if they injected contrast or state pre contrast films, and post films. That is what I rely on is how it's dictated. With and without is always confusing and you can not charge for oral contrast and the Doc's always, without fail call it contrast. If it has pre and post films and pre is with oral contrast, it is w/o (without) contrast, then the post films of contrast (with contrast) you will have a true with and without charge.
 
I agree that one should code based on the documentation within the body of the report however, when there are discrepancies, whether between the header and the body of the report or other; verifying with the physician is the best practice. If necessary have the physician make an addendum to the report to clarify incorrect or confusing information. Sometimes an incorrect header is simply a reflection of errors made in charge entry.
 
Yes you should code by what's in the title not what's in the order. The order could have been written/typed wrong. If you can ask your rad to confirm, I would do this first. If not, then go by what's in the body of the report.
 
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