Wiki Out-pt diagnostic tests

[jfogelquist]

I was an In-patient coder and I am new to the out patient world. My questions is...

When a patient comes in to have an x-ray at our facility they bring with them a writen script for their PCP. I have read the rules that we can code the diagnosis from the script (Hip Dysplasia)

What if the radiology report is in the account at time of coding and their "Findings: Faint mineralization of the left femoral head is seen which is well seated in the left acetabulum. Slightly shallow left acetabulum is seen. Right femoral head also shows faint mineralization and is well seated. Right acetabulum is less shallow than the left one. No other interval change is seen. Followup study is recommended."

Do I use Hip Dysplasia still as my Pdx even though the femoral head is well seated?

Under the guidelines S.IV... L. Pt receiving diagnostic services only... For out-pt encounters for dx tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitiave dx documented. To me a physician is not a radiologist and we shouldn't code from the radiology report.

What if the patient comes in for pneumonia, has an x-ray done and radiology reports states No pneumonia?

Thank you in advance for your help

Jennifer

 

[boozaarn]

probabely

you need to ask the pcp for symptoms. (pain/cough/fever ect.) sometimes i use the v code for screening for suspected condition.

 

[nbarger22]

Documentation needs to come from the doctor. Here at our facility we don't use any dx from the rad report. I would query the doctor on why he is doing the test....signs/symptoms. Hope this helps!

 

[Tonyj]

I was an In-patient coder and I am new to the out patient world. My questions is...

When a patient comes in to have an x-ray at our facility they bring with them a writen script for their PCP. I have read the rules that we can code the diagnosis from the script (Hip Dysplasia)

What if the radiology report is in the account at time of coding and their "Findings: Faint mineralization of the left femoral head is seen which is well seated in the left acetabulum. Slightly shallow left acetabulum is seen. Right femoral head also shows faint mineralization and is well seated. Right acetabulum is less shallow than the left one. No other interval change is seen. Followup study is recommended."

Do I use Hip Dysplasia still as my Pdx even though the femoral head is well seated?

Under the guidelines S.IV... L. Pt receiving diagnostic services only... For out-pt encounters for dx tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitiave dx documented. To me a physician is not a radiologist and we shouldn't code from the radiology report.

What if the patient comes in for pneumonia, has an x-ray done and radiology reports states No pneumonia?

Thank you in advance for your help

Jennifer

Jennifer, a radiologist is a physician.

When coding outpatient diagnostic services, you can code from the impression as well as the findings. I'd use (793.7 Nonspecific abnormal findings on radiological and other examination of body structure; musculoskeletal) due to the "faint mineralization" comment and follow-up recommendations. You can also use the signs and symptoms of the patient if the are properly documented by the radiologist and/or the technician.

Tonyj

 

[Tonyj]

nbarge22, is a radiologist not a doctor? Propose that same question to your pcp and please let me know what his/her answer is. The reason the patient has a radiological study is to provide the ordering physician with an appropiate diagnosis, etc......

It seems that you may be confused.