Wiki Nonspecific abnormal findings on outpatient dx testing

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Ldari

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Curious how others are coding radiology encounter where abnormal findings are mentioned in outpatient encounters? Any guideline references would be helpful...

Examples:
MRI Brain w/ Impression states "Abnormal densities within white matter, recommend follow up MRI is 6-12 months" Would you then code R9402 or does this fall in to the "uncertain diagnosis" guidelines and therefore is not coded.

Hysterosalpingogram w/ impression "subcentimemter focal filling defect in the lower uterine cavity, which could represent an air bubble, clot, or pedunculated lesion" Would you code R948 or disregard statement?

Related guidelines.
B. Abnormal findings
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.
Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider.
 
Radiology - Abnormal Findings Brain and Uterus

  • R94.02 is for a Nuc Med Study.
    [*]     R94.8 is for a function study.

    Please see below


Section*R90*-*R94
Diagnostic imaging includes traditional x-ray exams, CT scans, MRI scans, PET scans, thermography, and ultrasonography. Function studies include nervous system studies such as electroencephalogram (EEG), electromyography (EMG), electro-oculogram (EOG), visually evoked potential (VEP), auditory and vestibular function studies; pulmonary function studies; cardiovascular function studies such as electrocardiogram (ECG) and intra-cardiac electrophysiological studies (EPS);*and kidney, liver, thyroid, and other organ or body system specific function studies.

MRI Brain w/ Impression states "Abnormal densities within white matter, recommend follow up MRI is 6-12 months"
R90.89 Other abnormal findings on diagnostic imaging of central nervous system.


Hysterosalpingogram w/ impression "subcentimemter focal filling defect in the lower uterine cavity, which could represent an air bubble, clot, or pedunculated lesion" Would you code R948 or disregard statement?
R93.8 - Abnormal findings on diagnostic imaging of other specified body structures
 
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