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coding off of radiology reports- help

  1. Unhappy coding off of radiology reports- help
    Medical Coding Books
    At the hospital I work at, I was told I can't code from the body(findings) of the radiology report because the Radiologist is just putting his thoughts down of what is going on. I am told to just code from the dx, interpretation and impression fields. Sometimes there are things in the body area that seem important to me and that cover LMRP issues, but I can't code them. What to do? Anyone have any input?

  2. #2
    ICD-9 Coding Guideline - as of October 1st, 2009

    Section IV - Diagnostic coding and reporting guidelines for outpatient services

    L. Patients receiving diagnostic services only

    For patients receiving diagnostics services only during an encounter/visit, sequence first the diagnosis, condition, problem or other reason for the encounter shown in the medical record to be chiefly responsible for the outpatient service provided during encounter. Codes for other diagnosises (eg chronic conditions) may be sequenced as additional diagnosises.

    For encounters for routine laboratory/radiology testing in the abscence of any signs, or associated diagnosis, assign V72.5 and a code from subcategory V72.6. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the V code and the code describing the reason for the non-routine test.

    For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnosises.

    So, I guess the answer is no, unless the provider mentions something about it in the interpretation or in his notes. I come across this a lot and I know it is hard not to code what you see in the actual x-ray, even if it helps, but you can not code to get paid and we are the coders, not the providers, so even if we see something, we can not add any official diagnosises. If it is something that you might think that the physician missed that is integral to the disease process that is being looked at, then by all means, query the provider. In the cases of x-rays, though, that is not always an option. Good luck

  3. Default radiology coding
    Thank you so much for responding, Leslie. You have helped me a great deal!
    Randi Renninger, CPC-A

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