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Guideline for coding radiology

  1. Default Guideline for coding radiology
    Medical Coding Books
    I am having a discrepancy with some of my rads and ortho doctors (that read their own films). I know that they are suppose to have the indication, number of views, body and then impression. Myself as a coder can I code off the body for example. An abdominal series: Indication: abdominal pain.
    Body states pt has a small renal cyst and small ovarian cyst. But his
    impression states: normal. If the rad, doesn't want to do any correction can I code the renal cyst & ovarian cyst. Or do I just code off the impression which states normal thus I would code the abdominal pain. Hope this isn't confusing. I have found some info in Radiology Management about coding but it doesn't specifically state that a coder is suppose to just code off impression or reason for study. If there is a formal guideline out there could you let me know where to find it

    thanks, Marsha

  2. #2
    Albany, New York
    I feel for you.....

    Okay.....if I am coding an Amb Surg case, I do pick up conditions that the surgeon notes in the body of the OP report.
    If I were coding the scenario you describe above, I would go with the indication/ symptom.
    Karen Maloney, CPC
    Data Quality Specialist

  3. #3
    Birmingham, Alabama
    Either would be ok, the document supports both choices. However, since the radiology stated normal, that implies he/she does not think the cysts are the cause of the pain. Therefore, I would code abdominal pain as the primary (because that was the reason the test was ordered) and sequence the others as incidental findings.

    hope this helps.

  4. Default Guideline for coding radiology
    Always relate the impression with the Chief Complaint. Here in the Example you Quoted, It is best to code abdomen pain because ovarian cyst & renal cyst are incidental findings & may not be the reason for abdomen pain. In the same case if the impression states Renal Stone or an Appendicitis you will code from Impression only. Hope this Helps you!!

  5. Default
    Thank you everyone; it does clarify things for me allot better. I know some
    facilities have compliance issues with the coding of radiology but our facility does not have clear guidelines in regards to this. Thanks again,,,Marsha

  6. Default kaviarasu,cpc
    marsha ,
    i do get documents like this , i only think ( the reason for the visit (the symptom must resumble in the impression orelse in body , but here we are not sure that he/she gets abdomen pain because of the cyst , and that cyst might not be in a seveire condition and probably have no connection with the abdoman pain ) if so it must be confirmed in the impression,

    but if not better to choose the reason(symptom)

    thanks kavi, cpc

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