# Radiology diagnosis coding



## mcrossley (Apr 23, 2019)

Hello,

I am just wondering if I can other opinions on radiology diagnosis coding.  
1) If a report states that a patient got inured, and the impression states there is a sprain of a ligament, but also states there is osteoarthritis...would you just code the sprain or would you also include the osteoarthritis as the secondary?
2) If a patient has a brain MRI and is seen for dizziness/facial droop and suspected stroke, but the impression just lists atrophy and ischemia...would you code fort the atrophy and ischemia or the sypmtoms?

Just looking for input since there are different answers within our office on how people would code.

Thanks!


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## pscanlan (Apr 24, 2019)

I think the main thing is to nail the primary diagnosis. Basically the primary is the only one that faces scrutiny from the payers in justifying the procedure. 

1) Presenting illness or chief complaint is the injured ligament. Any other diagnoses that could affect treatment (your provider's or another's) should be coded as well. This includes the OA, any hypertension, heart disease, diabetes, etc. in the patient's recent history. Frequently, comorbidities (chronic secondary diagnoses) increase the complexity of the treatment required, or the number of areas or structures covered by an imaging study. I would include these as a matter of course, in case a payer ever questions the duration or complexity of your procedures. 
2) I would code first the dizziness or facial droop, then anything the findings detail, TIA, cerebral insufficiency, etc. Note: suspected stroke is not a thing. Rule out stroke is likewise not a thing. You either had a stroke or you didn't, and you can't put a stroke ICD on a patient just because you think he might have had one. I'd code the symptoms as primary, because you cannot be sure before doing the imaging that there was a stroke. You may get varying opinions on this one. I've heard of people waiting for a post-op Dx before billing the claim, but I don't hold with that. If you can't justify the procedure based on the pre-op diagnosis, then you can't justify doing it in the first place. 

Hope this helps.


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## thomas7331 (Apr 24, 2019)

pscanlan said:


> I think the main thing is to nail the primary diagnosis. Basically the primary is the only one that faces scrutiny from the payers in justifying the procedure.
> 
> 1) Presenting illness or chief complaint is the injured ligament. Any other diagnoses that could affect treatment (your provider's or another's) should be coded as well. This includes the OA, any hypertension, heart disease, diabetes, etc. in the patient's recent history. Frequently, comorbidities (chronic secondary diagnoses) increase the complexity of the treatment required, or the number of areas or structures covered by an imaging study. I would include these as a matter of course, in case a payer ever questions the duration or complexity of your procedures.
> 2) I would code first the dizziness or facial droop, then anything the findings detail, TIA, cerebral insufficiency, etc. Note: suspected stroke is not a thing. Rule out stroke is likewise not a thing. You either had a stroke or you didn't, and you can't put a stroke ICD on a patient just because you think he might have had one. I'd code the symptoms as primary, because you cannot be sure before doing the imaging that there was a stroke. You may get varying opinions on this one. I've heard of people waiting for a post-op Dx before billing the claim, but I don't hold with that. If you can't justify the procedure based on the pre-op diagnosis, then you can't justify doing it in the first place.
> ...



Well said, I agree with this for the most part - the primary diagnosis should reflect the reason for the test, and as coders, we can't draw conclusions from the interpretations, only code what they are.  So in the second example, I agree that the symptoms should come first, since you can't assume that the atrophy or ischemia in the impression was the cause of those symptoms, but they can be coded as additional diagnoses since they are being evaluated.  

The only area where I'd differ is that I wouldn't code 'any other diagnoses that could affect treatment' - the guidelines state that we should code those conditions that _require or affect patient care treatment or management_, not ones that could just potentially affect treatment.  I think that the documentation needs to support that the condition actually did play a role in the encounter, not simply that it could affect future treatment - otherwise we can end up doing what's sometimes called 'kitchen sink coding', i.e. putting in every possible code whether it's relevant or not.  But that's really an area your management should guide you on as different organization may have different reporting requirements for comorbidities.


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## ketevan.khmelidze@yahoo.com (Apr 24, 2019)

Well, I attached the snip from AAPC trainng. Hope it helps. It definitely suggest to use interpretation dx for biiling


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## Kmarsella21 (Jun 4, 2019)

I have been looking for radiology quick reference ICD 10 cards... has anyone come across any?


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