radiolucent lesion on x-ray

tag60

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Pt in for follow-up of knee pain. Provider states pt had an x-ray that shows a 10 mm radiolucent lesion in proximal tib-fib.

Provider's diagnosis: Knee pain. He orders refill of med and another x-ray "to see what the lesion is."

Do I code only the knee pain -- or do I also code the x-ray finding, R93.6 (Abnormal findings on diagnostic imaging of limbs), or is that making an assumption that it is abnormal? (From my research, I read that such lesions are often benign...but then provider is ordering further workup.)

Thanks in advance!
 
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look for this

Coding Clinic, First Quarter 2014: Page 18
Coding Clinic, First Quarter 2013: Page 28


in the inpatient setting, abnormal findings are not coded and reported unless the provider indicates their clinical significance. If the finding are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provide whether the abnormal finding should be added.

In the outpatient setting, if the diagnostic tests have been interpreted by a physician, and the final report is available at the time of coding, it is appropriate to code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

In terms of coding and reporting for hospital inpatients, according to the Official Guidelines for Coding and Reporting, Section III.B., it would not be appropriate to code abnormal findings from radiology reports.
 
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