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I have a question to anyone who has been coding Radiology. And I apologize if this something pretty common/simple. I've been researching on this for days and about flustered - LOL

I recently moved across country and started a new position. I code Family Med as well as all Imaging done at the Hospital Radiology department. We only do the Technical part (TC). We send the imaging off to a contracted Radiologists group to read them, they bill their part and send us the reports/reads. I came from Oncology/Hematology and the company owned their own PET centers. I coded the imaging there too, but we only put the DX for what the image was ordered for (TC only). We didn't add the findings from the reports. But here they are coding from the report as well and putting all the finding DX too on the billed out claim. If this is correct that is no problem, and guess it was done wrong at my other employer. I just never had done that and was looking into it for my friends who are still at my old job. They wanted to make sure they were doing things right when they found out how I was doing it here. I just was curious if this was a required guideline on coding Radiology or if this was just the way i was done here. No one here seems to know when I ask. They just say that is how they have always done it.

Does anyone have an reference to these rules too. I find tons of info on the Modifiers and CPTs, but not on the DX coding. Thanks so much in advance for any help.

GrInS :)


We just did 76830 - TC and 76856 - TC for irregular Menstruation

Finding in the report was Simple Left Ovarian cyst and Subserosal leiomyoma of uterus

would you code all three or just the main reason for the image?