Implying/Assuming Laterality

suemt

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I know coders aren't supposed to assume, but does anyone have an authoritative source for nuances of this rule?

For example, if the indication is "pain" but the report says left foot xray and the impression is normal left foot, I would say you can't assume the indication was left foot pain and that the provider should be queried. I'm being told (in so many words) this is ridiculous and would be a waste of the doctor's time. I say that not only is it necessary to confirm from a coding perspective, but having the laterality in the order/indication is a double check that the radiologist looked at the correct foot!

If I'm being too strict, I will lighten up, but if I'm not, I'd like to have something to support me.

Thanks in advance for any help!
 

Cheezum51

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I would say that you are correct to do what you're doing. If the provider isn't recording the HPI, or other portions of the exam, completely so you know the laterality for proper coding, then they need to be educated on proper complete record keeping by someone so that, in the event of an audit, there are no questions or problems.

Tom Cheezum, O.D., CPC
 

suemt

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It's radiology, not E/M visits, so not quite the same opportunity to pick up info in another spot.


I would say that you are correct to do what you're doing. If the provider isn't recording the HPI, or other portions of the exam, ...
Tom Cheezum, O.D., CPC
 

Cheezum51

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Wouldn't the orders from the provider requesting the imaging study contain some wording indicating laterality that would then flow through to what the radiologist does for your coding purposes?
 

suemt

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You would hope, however for this situation, I only have access to the radiology reports.
 
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