Thyroid Ultrasound

jnieto625

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37
Location
Savannah, GA
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Correct me if I am wrong.... I have always coded our ultrasounds with the actual findings (which is what I was always taught) unless the findings are normal in which case I code the symptom/reason the exam was ordered. I have thyroid ultrasound ordered due to a thyroid nodule but the ultrasound is normal. When I went back to the provider she argued that based on her exam, she thought she felt a thyroid nodule. I then suggested she order these under R22.1 (localized swelling, mass and lump, neck) until the report confirms the suspected diagnosis. She does not agree and will not correct the diagnosis on the order. My question is... How am I supposed to code this if the order states thyroid nodule???:confused:
 

luhre

Networker
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64
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Syracuse, NY
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Coding Data Analyst, CPC

You would have to code the nodule, E04.1 unless the Radiologist "indication" in the report was neck swelling/lump.
 
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