Wiki Radiology Professional Charges

[amyfust]

I am getting conflicting information so if someone can answer my question and tell me where to find the rule I would really appreciate it. I code Radiology and Interventional Radiology and with the new ICD-10 some are saying that my coding should only be off of the patients s-ray report or order for the exam and not allowed to look in that patients visit with the ordering physician to figure out what symptoms the patient was having and why the physician ordered a particular set of x-rays. Please help me solve this issue. Thanks, Amy

 

[amymeyers01]

Rad diagnoses

I don't think there is "official" authoritative guidance on this issue, but most rad practices go with "if it isn't in the report, you can't code it." I have had clients/companies, over the years, who will allow the diagnosis off of the order and I have some who allow it to come from the patient's file as long as it is documented on the same date of service. My personal opinion is that the implementation of EHRs that are linked with the hospitals so you can easily show where the diagnosis came from, will mean we can draw from the patient records.

You might want to check the Medicare online manual to see if it says one way or the other. I believe it is chapter 13 for radiology. I haven't checked in a while because I work for a company that outlines their policies when you are assigned to the client.

I hope this helps! There is quite a bit of gray area on this subject.
Amy