# radiology incidental findings



## fisherdawnmarie (Apr 3, 2008)

If the only symptom is abdomen pain for an adomen ultrasound or ct would any definitive diagnosis be considered incidental without knowing the exact location of the abdomen pain?


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## 007CPC (Apr 4, 2008)

*Is this what you mean*

The incidental diagnosis located from the abdominal ultrasound or CT technique is the etiology of the manifestation-Abdominal pain. In a coding scenario such as this the abdominal pain is considered an integral of the robust diagnosis which should be coded first. Your incidental diagnosis has to be documented as the present purpose of the present service rendered.

I don't code anymore so were going to have to wait for the coders to wake up. Try asking abishard or KevinShields who have contemporary experience in the radiography specialty.


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## kevbshields (Apr 4, 2008)

Ditto on what Chad so very eloquently said...


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## abishard (Apr 4, 2008)

fisherd said:


> If the only symptom is abdomen pain for an adomen ultrasound or ct would any definitive diagnosis be considered incidental without knowing the exact location of the abdomen pain?


In this case it would depend entirely on what the findings are...I usually code findings when they are something acute and the radiologist emphasizes the findings in his results... If they find diverticulitis or an obstructing calculus, then I almost always code that first.. What were the findings?


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## fisherdawnmarie (Apr 4, 2008)

The findings are fatty liver, renal cyst, & diverticulosis.


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## abishard (Apr 4, 2008)

I would definitely code abdominal pain first. I almost always code the symptom, or reason for exam first, unless there is an extremely acute condition and/or the radiologist states that is the reason for the symptom.. I hope this helps...


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## 007CPC (Apr 4, 2008)

*AHIMA vs. AAPC*

You couldn't ask for a better example that distinguishes between Healthcare coding vs. Corporate coding! Wouldn't you agree Kev.


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## kevbshields (Apr 7, 2008)

ICD states not to code any associated signs/symptoms integral to a disease process.  

If a Radiologist confirms a definitive dx, then that should be coded for the exam.  Incidental findings ought to be added, based on facility policy.


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