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Thread: Coding to the highest degree

  1. #1

    Question Coding to the highest degree

    AAPC: Back to School
    I am being told by people in my office, who do not code, that on a radiology interpretation report that I only have to code one diagnosis code and that the highest degree means the most important on that report. I code all that is listed on the interpretation reports up to the four code maximum on our systems. I have argued this point to the point of pulling my hair out and those who do not code argue their point almost daily. Could someone please settle this argument and provide me with the proof needed to stop this constant bickering? Thank you

  2. #2
    Join Date
    Apr 2007


    Just out of curiosity, why is the point of view of someone who does not code important when there is a coding issue at hand? I don't know exactly where this info can be found, but I would imagine you could find it in the coding guidelines in the front of your ICD-9 manual, or somewhere on CMS' website, that's always a good place to find info.

  3. #3
    Join Date
    Apr 2007
    Louisville, KY


    You are not alone on this "battle." I've fought it myself.

    Here's what I recommend:

    1.) 2008 ICD-9-CM, under Section IV (Diagnostic Coding & Reporting Guidelines for Outpatient Services), part L, third paragraph, "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 diagnoses."

    This typically includes any incidental findings, or additional "abnormalities" noted on the report. Keep in mind that even if we are coding inpatient, professional fee, we still abide by the OP guidelines.

    2.) Also in ICD, under Section I.B.8, "Conditions that are not an integral part of a disease process . . . should be coded when present."

    3.) Per the ACR (these are the Radiology practice guidelines--general, diagnostic):

    "Findings that the diagnostic imager
    reasonably believes may be seriously
    adverse to the patient’s health and are
    unexpected by the treating or referring
    physician," should be communicated to the requesting provider. Basically it is saying that things reported in the findings or body of the report (and deemed important to the examiner) are worthy of mentioning. Inasmuch, if it is mentioned in the impression, I would say it should definitely be coded.

    What you're doing is fine. If these "non-coding" folks have objections, tell them to forward their queries to ACR and ICD.

    Hope this helps.
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

  4. #4


    They just so happen to be the managers and since payroll goes through them then I try to accomodate whenever possible.

  5. #5


    Thank you so much for you informative reply. You gave me just the information that I needed.
    Tina Houseright

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