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E/M Diagnosis question

  1. #1
    Location
    Burlington, Vermont
    Posts
    10
    Default E/M Diagnosis question
    Medical Coding Books
    My question is when I have a progess note and there is no clear diagnosis given by the doctor, however there are results listed in the x-ray/MRI taken can I use the information from the x-ray/MRI. I been told no we can't and I've also been told that we can. HELP which one is it.

  2. #2
    Location
    Columbia, MO
    Posts
    12,837
    Default
    Was the MRI and xray performed on the same day as the physician encounter? If so then yes you may use the dx indicated by the radiologists as he is a physician. If not then no you cannot, you can use the signs and symptoms documented.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    Burlington, Vermont
    Posts
    10
    Default E/M Diagnosis question
    Mitchellde - thank you so much for your quick response to my question. If you are able, would mind telling me where I can find the documentation to support that I can code from the x-ray that would be great. If you read me earlier response, I hope I didn't offend you. After I sent the earlier message, I realized that it sounded rude.
    So, again my apologies
    Last edited by Dug94Jen; 06-24-2010 at 09:00 AM.

  4. Default
    It would be always better if the visit attending confirms the x-ray finding (radiologist's) to report the diagnosis.
    Thanks,
    Jagadish, CCS-P, CPC

  5. #5
    Location
    Columbia, MO
    Posts
    12,837
    Default
    I found it stated in the coding guidelines from several years back, you can utilize diagnosis rendered by physicians and a radiologist is a physician.

    Debra A. Mitchell, MSPH, CPC-H

  6. Default
    While coding office visits, I observed many times that visit attending contradicting radiologist's opinion.
    Thanks,
    Jagadish, CCS-P, CPC

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