# Dx code ?



## Kimberley (Dec 12, 2008)

Hx: back pain/history esophageal CA

Pt had an MRI T-spine and the impression shows:

ABNORMAL MARROW SIGNAL OF T6 AND T7 vertebra.  Proobably this represents bony metastatic disease but recent compression injuries from other etiolologies could potentially have this appearance.

Would just using 724.5/v10.03 be appropriate? Or is there a code for abnormal marrow?


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## heiditipherwell (Dec 12, 2008)

You could use the abnormal radiological exam for musculoskeletal  793.7

The 793.xx codes are great for stuff like that.

Hope that helps.
Heidi


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## HixsonM (Dec 12, 2008)

Kimberley said:


> Hx: back pain/history esophageal CA
> 
> Pt had an MRI T-spine and the impression shows:
> 
> ...


I would only code those two diagnoses for that office visit.  Coders can not pull findings from a radiologic report, so unless the physician wrote Abnormal Radiologic Findings or Disorder of the Marrow on the progress note you could not code those diagnoses for that visit.

But I would think that you would need additional information, such as 289.9 for Blood Dyscrasia or disorder of the marrow. It would depend on the situation. I would ask my physician for additional guidance on this. The patient could have polyneuropathy or some other disease state in the health history that would explain it, but it is important for a risk assessment stand point to accurately describe the status of the CA. Is it truly history, remission, or is it active again... 

As you know R/O and possible/probably do not help the coder, but you could always use the abnormal radiological codes if this is the physician’s assessment. If there is not a clear correlation to the marrow issue and the back pain and/or history of CA then I would code just as you had indicated with back pain and history of CA. 

If this is a Medicare or MCA plan member then the risk value would not be assessable in any of the scenarios, and I assume that the question is coming from the interpretation standpoint.


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## Anna Weaver (Dec 12, 2008)

*dx code*



HixsonM said:


> I would only code those two diagnoses for that office visit.  Coders can not pull findings from a radiologic report, so unless the physician wrote Abnormal Radiologic Findings or Disorder of the Marrow on the progress note you could not code those diagnoses for that visit.
> 
> But I would think that you would need additional information, such as 289.9 for Blood Dyscrasia or disorder of the marrow. It would depend on the situation. I would ask my physician for additional guidance on this. The patient could have polyneuropathy or some other disease state in the health history that would explain it, but it is important for a risk assessment stand point to accurately describe the status of the CA. Is it truly history, remission, or is it active again...
> 
> ...



You say we cannot pull codes from a radiologic report, I was under the impression we could. The coding guidelines state "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." If the radiologist interprets it, then you say we can't use it? Anyone else?


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## Kimberley (Dec 12, 2008)

This is a radiologic report


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## mkj2486 (Dec 17, 2008)

When I was trained for Radiology coding, I was told we could use "Abnormal Findings" if the Radiologist saw something abnormal on the x-ray.  We can't use the Radiologists impression of what might be the diagnosis, unless the physician confirms a diagnosis, but an abnormal finding is OK because it is not a diagnosis.  

I would like to hear more from other coders in regards to this.


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## kmhall (Dec 17, 2008)

*Agree*

I agree with Anna.  If results of a specific test are known at the time of coding, that specific diagnosis SHOULD be coded.


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## Kris Cuddy (Dec 17, 2008)

Absolutely agree that diagnoses may be coded from the findings of a radiological report. Diagnostic studies should be coded based upon the findings, if they are available. If the findings are normal, then the sign(s) and/or symptom(s) that led the patient to the diagnostic study should be reported.

ICD-9 CM, Coding Guidelines, Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services, section L; Patients receiving diagnostic services only, and the last paragraph of section L reads, _"For outpaient 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 signs and symptoms as additional diagnoses."_

It makes sense, then that if there is no report available, to code based upon sign(s)/symptom(s), yet if one is available to code from that.

As there is no definitive diagnoses in the report but there are abnormal findings listed, it would not be inappropriate to code the abnormal finding ICD-9 code related to the study. In addition, with no definitive diagnosis, it would also seem appropriate to code the sign(s)/symptom(s) from the order that prompted the study.

Hope this helps.


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