Wiki Question re "incidental findings"

[eguest]

If a patient comes in with a chief complaint of a one sided problem, let's say for example, right knee pain, and the physician documents arthritis in both knees and performs xrays on both knees and does document in the dictation his bilateral findings, can we bill for the left side xrays or is that "incidental" since the chief complaint was only for the right side? Of for another example, if the patient comes in for right sided knee pain but the physician had done a left knee replacement in the past, so again he performs xrays on both knees, can we bill for the left knee xray even though only the right side was the chief complaint on this encounter? Again, the provider does document bilateral xray findings.
thank you.
Elaine G.

 

[jhartung]

I believe that if the physician documented the procedures performed they must be coded regardless of what the patient came in for. Leaving them out would be undercoding, or at least I think so. And of course you would want to ensure that the diagnoses given support the procedures performed.