Wiki Radiology for Pain due to Trauma with incidental finding

[malsers812]

I am looking for the guidance/documentation that supports continuing to code pain due to trauma when no injury is found but there are other incidental findings.

We are coding radiology (xray, CT, etc) after the patient has some kind of trauma or accident with the indication of pain associated to trauma or fall. When no injury is found but there is documented osteoporosis or a bone spur ( which in other situations would be the source of the pain) but is not the cause of the pain here. Therefore, no final diagnosis was found for this acute problem and the pain should still be coded. There are a few people who are arguing that pain should no longer be coded with a present confirmed diagnosis and I am looking for some supporting documentation that it should be since this pain is unrelated. Does anyone know if this exists?

 

[whatwouldyousay]

I agree with you! Look at 2023 ICD-10-CM Official Guidelines for Coding and Reporting; B; #4 and #18. Feel free to reach back out if you need more help arguing your case. Exam is indicated for acute injury and there is associated pain. To code a chronic condition would be incidental and not provide medical necessity for the imaging performed. It is appropriate to use an ICD10 for signs and symptoms in the absence of a related and definitive diagnosis. Unless that report states that the pain the patient is experiencing is definitely due to the incidental osteoporosis finding and not related to the acute injury (which it will not ever say), it would be inappropriate to use osteoporosis as the primary diagnosis.