Wiki Laterality

[Awren]

Hello all,
Can anyone provide me with some guidance as to coding laterality on x-ray orders? Any x-rays done at our facility are done as an outpatient service. With this in mind, the only thing I have to code from is the order itself. I have a provider who is requesting that I assume the laterality of a diagnosis based on the x-ray that was done. For example, provider ordered a right wrist x-ray 3V, but the diagnosis on the order is M25.539, pain in wrist NOS. This provider wants me to code it to M25.531, pain in right wrist, stating that it was the right wrist that was ordered. I am not so comfortable doing this & would like to get others opinions.

Thanks,
Angela

 

[chembree]

In my opinion that is a very risky liability for the provider to take on. Images can be done for comparison services or due to a disease that is present on one side that they are ruling out or staging on the opposing side. I agree with you that I would not be comfortable doing this and if you are required to code this way I would get something in writing from the provider and make sure he/she knows they are accepting full responsibility if there is a discrepancy.