Wiki Radiology outpatient coding and where to pull the dx from? The radiology report or the order?

[Cnichols10]

I am a new coder and I have been put in charge of coding radiology, from CT to Echos to plain xrays etc etc...... My question is when I get an order that says they are sending the patient to get a DEXA scan for screening purposes (which is not covered) and then the radiologists finds the patient does have Osteoporosis, do I code what the order says or do i code what the radiologist finds.
This is my basic issue- the doctor will order for whatever reason that is not medically necessary and then the radiologist will find something that is medically necessary. Am i required to code the dx code on the order or can i just code the findings from radiology?
I have asked several people and seem to get a different answer each time. The guidelines talk about incidental findings but im not sure if it applies to xrays or not. Im very confused being new to all this and unsure of what to do. I just want to do it the correct way. Please help!!!!
Thanks Cindy

 

[TThivierge]

Hi Cnichols10
Here is the data hope will help you...patient arrives, with pain or symptom required xray or MRI or CT or ultrasound done, then you read the results along with order from attending/referring provider. Naturally this should be medically necessary. Try to have them give you sign or symptoms or definitve dx codes not just Z dx codes . As example patient has pain in lower right leg , then use pain in leg dx M79.604 if nothing found. .After results then the radiologist locates the patient has muscle benign lump or tumor in his leg then use dx D21.21, then this should be reported. At time the xray show nothing so leave the a reason why getting xray. But sometime the radiologist will state there is abnormality need more care done, then see dx R93-R94 blocks attaining to the body part.

Also if patient gets a MRI or CT and has had same Xray about a year or 2 years ago put a modifier on it of PS or PI. Also add contrast material if put in vein or joint. If contrast is swallowed or enter in rectum do not code it ...bundled in. Types of contrast is done like fluids... isouve,iodine, or gadolinum. The HCPCS done for one of them is A9952 to bill on claim if this is done the radiologist will add it in his or her report. Also put on claim the referring doctor, laterality modifiers of 50, RT or LT, TC or 26 when applicable.
Oh yes if xray is due to some kind of injury such as: car accident, dog bite, fall, Etc ensure put date injury happened, where ,and how ......payers will want to know.
I hope helped you somewhat,....but clear process with your facility. This is just my past coding experience and old coding textbooks. 321 Code It and Buck's Coding Step by Step.
Lady T