outpatient radiology/diagnsotic coding

hspruill

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Local Chapter Officer
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I have a couple of questions brought up by audits and discussion with coworkers. just looking for a general consensus;
when a patient comes in for ancillary ops radiology in our facility (hospital) - the rad tech enters notes under "indications" - I was taught to not pick that up unless the radiologist confirmed it in the body of the report or in the conclusion. I have learned that some co-workers say that they do pick it up b/c "doesn't the radiologist sign off on the whole report?" I haven't found any clear guidelines on this in official guidelines or in coding clinics. 2nd question is where to draw the line on what is picked up from the body. do you code for "mild" findings, but leave out "minimal/trivial" do you pick up "incidental" (I do not). thanks all for your input. :) :) we are trying to get our whole coding team on the same page.
 

BevMoore

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We only code the Dx that are listed in the Final Impression on the Radiologist report. We do not code any Dx from the "body" of the report. If there is no definitive Dx listed in the Final Impression for the pt's s/s, then we code the s/s.
 
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