# coding radiology-Can someone please



## mommacode (Oct 23, 2013)

Can someone please tell me the real, true, 100% correct rules on coding from radiology reports. When you have your order and it contains a reason for the test and also a symptom would you leave off the symptom as you would in all other coding scenarios? 
Is it appropriate to code from the clinical indication, reason, narrative, etc at the top of the radiology report if those same reasons are not listed on the actual order? 
Is it appropriate to code anything in the body of the report that is not stated in the impression?


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## chembree (Oct 24, 2013)

Below are the rules as listed by CMS. I will say I only use the report as my coding source. Not the order. We have hospital based radiologist and I often do not have access to the order. 

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf

Rules for reporting diagnosis codes on the claim are: 
• Use the ICD-9-CM code that describes the patient's diagnosis, symptom, complaint, condition or problem. Do not code suspected diagnosis. 

• Use the ICD-9-CM code that is chiefly responsible for the item or service provided. 

• Assign codes to the highest level of specificity. Use the fourth and fifth digits where applicable. 

• Code a chronic condition as often as applicable to the patient's treatment.

• Code all documented conditions that coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions that no longer exist.) 

For outpatient claims, providers report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in the appropriate FL. For instance, if a patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom is reported (786.2). If, during the course of the outpatient evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the definitive diagnosis is reported (466.0).

The CMS requires following the ICD-9-CM Coding Guidelines for Outpatient Services (hospital-based and physician office). These guides instruct physicians to report diagnoses based on test results, if available. The Coding Clinic for ICD-9-CM confirms this longstanding coding guideline.

A. Confirmed Diagnosis Based on Results of Test 
If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis.

A. On the rare occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient's medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician.


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## mommacode (Oct 24, 2013)

ok, I guess my biggest question is, How do you determine if the reason for the test should be sequenced as the primary dx or the findings? For example, if the ct of the abdomen is being performed for abdominal pain and the impression states fatty liver, diverticulosis, and hiatal hernia do you still code abdominal pain as the primary even though abdominal pain is a symptom of all of those? What specifically helps you to determine whether the finding is substantial enough to be the primary?


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## chembree (Oct 25, 2013)

mommacode said:


> ok, I guess my biggest question is, How do you determine if the reason for the test should be sequenced as the primary dx or the findings? For example, if the ct of the abdomen is being performed for abdominal pain and the impression states fatty liver, diverticulosis, and hiatal hernia do you still code abdominal pain as the primary even though abdominal pain is a symptom of all of those? What specifically helps you to determine whether the finding is substantial enough to be the primary?



I would not code the abdominal pain in your example because you have plenty to code that can explain the abdominal pain.

See the below CMS guidelines: 

A. Confirmed Diagnosis Based on Results of Test 

If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that 
prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis.

EXAMPLE 1:
A surgical specimen is sent to a pathologist with a diagnosis of “mole.” The pathologist personally reviews the slides made from the specimen and makes a diagnosis of “malignant melanoma.” The pathologist should report a diagnosis of “malignant melanoma” as the primary diagnosis.
EXAMPLE 2:
A patient is referred to a radiologist for an abdominal CT scan with a diagnosis of abdominal pain. The CT scan reveals the presence of an abscess. The radiologist should report a diagnosis of “intra-abdominal abscess.”
EXAMPLE 3:
A patient is referred to a radiologist for a chest x-ray with a diagnosis of “cough.” The chest x-ray reveals 3 cm. peripheral pulmonary nodule. The radiologist should report a diagnosis of “pulmonary nodule” and may sequence “cough” as an additional diagnosis.


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## mommacode (Oct 25, 2013)

How do I apply the rules:   "If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that 
prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis."

How do I apply this to facility coding? What kinds of things clue you in that something is not fully explained or related to a confirmed diagnosis. If I have a ct of the abdomen for abdominal pain and diverticulosis and fatty liver are found, how would I know that I still needed to code the abdominal pain as my primary? What would indicate that these dx are not the cause for the abdominal pain?


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## chembree (Oct 25, 2013)

The only circumstance that would cause me to code a sign or symptom as opposed to a definitive diagnosis is if the physician excludes the diagnosis from being the source of the patient's pain. 

Also, I do not code incidental diagnosis codes. For example the patient has a CT of the abdomen and pelvis and the physician sees pneumonia. I would not code the pneumonia because it is incidental to the abdominal pain. 

ICD-9 states that signs and symptoms that are associated routinely with a disease should not be coded when present. Abdomen pain is a routine symptom of diverticulosis.

I hope this helps. 

Sincerely,

Christy Hembree, CPC
Team Leader-- Coding Dept.
Summit Radiology Services
www.summitradiologyservices.com


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## mommacode (Nov 5, 2013)

I agree with what you are telling me. The reason I was asking is that I am being told by person doing my reviews that I should only be coding the finding as primary if it is stated that it caused the symptom or it is stated in the order that they were ruling out what they ended up finding. I disagree with that. I'm not new to all this, been doing it for quite a while and now I'm being told to do things incorrectly.


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