Wiki ICD-10 Code on final dictated report

[ttompsett]

I'm looking for sources/documentation or any information on the risks involved with having the ordering provider's ICD-10 code listed on the final dictated radiology report. Can anyone help?

 

[CodingKing]

I'm looking for sources/documentation or any information on the risks involved with having the ordering provider's ICD-10 code listed on the final dictated radiology report. Can anyone help?

What risks are you thinking of. The ICD-10 guidelines spell out selection of diagnosis.

 

[ttompsett]

Here's an example- if the ordering physician ordered a chest x-ray for 'pneumonia' ICD J18.9 & the radiologist allows the indication portion of his report to state 'J18.9' but then acquires additional clinical information and dictates 'aspiration pneumonia' in his impression & the coder picks ICD J69.0 accordingly for the aspiration pneumonia- he would have a mismatch from what the indication states 'J18.9' and what the impression states & code used. I am assuming this presents some sort of compliance risk? So 1. What is the risk in doing this? And 2. Where can find documentation on this to prove this to the physicians (so they no longer allow the ordering ICD code on the final report)?

 

[JenniferB7]

Here's an example- if the ordering physician ordered a chest x-ray for 'pneumonia' ICD J18.9 & the radiologist allows the indication portion of his report to state 'J18.9' but then acquires additional clinical information and dictates 'aspiration pneumonia' in his impression & the coder picks ICD J69.0 accordingly for the aspiration pneumonia- he would have a mismatch from what the indication states 'J18.9' and what the impression states & code used. I am assuming this presents some sort of compliance risk? So 1. What is the risk in doing this? And 2. Where can find documentation on this to prove this to the physicians (so they no longer allow the ordering ICD code on the final report)?

I don't think there is a compliance risk with this. This is no different than surgical operative reports where the preoperative diagnosis and codes listed on the operative report may be different from the final, post-operative diagnosis and codes that also listed on the operative report and billed to the insurance carrier. It is understood that the findings during surgery or from pathology, or in your case from the radiology exam, may change the initial or ordering diagnosis. You obviously bill the more definitive diagnosis per ICD-10 guidelines, in your case J69.0 since diagnostic testing was able to provide a more definitive diagnosis. There should not be any issues with having the ordering provider's diagnosis and code on the final report since that documentation is also required to substantiate the medical necessity for ordering the test.

Does that make sense?