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dx coding for xrays

  1. #1
    Location
    Flint, Michigan
    Posts
    65
    Question dx coding for xrays
    Medical Coding Books
    All through college in my coding classes, we were told over and over that you DO NOT code for "suspected, rule out, possible" but now that I'm in a podiatry office I'm confused. What do you code for an xray due to a possible fracture, looking for a foreign body and so on but don't find a fracture or foreign body? My office manager (who isn't a CPC, has only learned through trial and error) says to code for fracture or foreign body. I'm not comfortable with this due to my training but don't know where to go for the correct info. Is she correct or is she miscoding? Please help!!!
    Marcia, CPC-A

  2. #2
    Default Coding for Xrays
    Quote Originally Posted by MarciaH View Post
    All through college in my coding classes, we were told over and over that you DO NOT code for "suspected, rule out, possible" but now that I'm in a podiatry office I'm confused. What do you code for an xray due to a possible fracture, looking for a foreign body and so on but don't find a fracture or foreign body? My office manager (who isn't a CPC, has only learned through trial and error) says to code for fracture or foreign body. I'm not comfortable with this due to my training but don't know where to go for the correct info. Is she correct or is she miscoding? Please help!!!
    Marcia, CPC-A
    You are correct, in an outpatient setting, you cannot code possible, suspect, etc. (this is in the coding guidelines in the front of your ICD-9 book) without definitive results in the xray, you would then fall back to the reason they took the xray, the reason they visited the office in the first place and the Doc decided to x ray. Pain, swelling, bruising, etc. There has to be some documentation somewhere for the reason for the test. They don't just decide on a whim. Fall back to the symptoms. Suspected fracture, or possible foreign body, is not good enough. If you can't find documentation in the patient chart, you can always go back to the Dr and get your answer.

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