Wiki Office Based Radiology Coding of Diagnosis

[duhll8803]

HELP!! In our practice we now employ our own Radiologists. These radiologists will read the various exams and will assess what they find on the report. I know as a coder for office based services that we would code the finding of the radiologist. Not what he suspects but actually what was found on the report. I have a compliance officer who is RHIT and who has insisted that we only code for what the test was ordered for. She is relating this to the rules of inpatient coding for radiologists that only provide the results and who the physician would then make the diagnosis. Now I could be wrong but from everything I see from the AAPC we should bill the radiologist finding and not the indication. As per the diagnosis guidelines if we have a definitive diagnosis or in this case a definitive finding we should code that and not the indication. Can any radiology coder help me with this problem. Thank you in advance

 

[mhstrauss]

HELP!! In our practice we now employ our own Radiologists. These radiologists will read the various exams and will assess what they find on the report. I know as a coder for office based services that we would code the finding of the radiologist. Not what he suspects but actually what was found on the report. I have a compliance officer who is RHIT and who has insisted that we only code for what the test was ordered for. She is relating this to the rules of inpatient coding for radiologists that only provide the results and who the physician would then make the diagnosis. Now I could be wrong but from everything I see from the AAPC we should bill the radiologist finding and not the indication. As per the diagnosis guidelines if we have a definitive diagnosis or in this case a definitive finding we should code that and not the indication. Can any radiology coder help me with this problem. Thank you in advance

See this paragraph from the following link (AHIMA). I know CMS has the same guidance, but from what I remember, its in one of the 20 internet manuals...I can't remember which one! Hope this helps some!!


In the outpatient setting (including physician offices), diagnoses documented as "probable," "suspected," "questionable," or "rule out" should not be coded as if they are established. Rather, the conditions should be coded to the highest degree of certainty for that encounter, such as symptoms, signs, abnormal test results, or other reason for the visit. For example, if the physician documents "fever and cough, possible pneumonia" at the conclusion of an emergency room visit, only the fever and cough should be coded, because those symptoms represent the highest degree of certainty for that encounter. However, if the physician documents "fever and cough, possible pneumonia" on a requisition for an outpatient chest x-ray, and the radiologist's diagnosis on the radiology report is "pneumonia," it is appropriate to code the pneumonia, as this diagnosis represents the highest degree of certainty for the encounter for the x-ray. Based on Coding Clinic for ICD-9-CM 17, no. 1, it is appropriate to code based on the physician documentation available at the time of code assignment.

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok2_000466.hcsp?dDocName=bok2_000466