Wiki Pulling diagnoses from radiology for E&M...

[Rita B. Conley]

Where can I find the guidelines for the coder to NOT assign diagnosis(es) for an office visit based on findings in a radiology or lab report. I remember learning this, probably way back in coding class years ago, but I'm not sure where the rules/guidelines can be found related to this. I need to educate a coder that we cannot "interpret" the radiology or lab findings and assign the diagnoses this way.

If anyone can help point me in the right direction, it would be greatly appreciated.

 

[valleycoder]

Did you look in coding clinic?

 

[mitchellde]

Where can I find the guidelines for the coder to NOT assign diagnosis(es) for an office visit based on findings in a radiology or lab report. I remember learning this, probably way back in coding class years ago, but I'm not sure where the rules/guidelines can be found related to this. I need to educate a coder that we cannot "interpret" the radiology or lab findings and assign the diagnoses this way.

If anyone can help point me in the right direction, it would be greatly appreciated.

You can report diagnosis from a radiology report since it is rendered by the radiologist which is a physician, however labs have not been physician interpreted therefore you may not use labs results for a diagnosis. Even abnormal lab may not be used until the physician states it is elevated or low or abnormal. This is in a coding clinic from years back, I do not remember which one.