Orthopedic Coding Alert

Question: If the physician hasn't indicated x-ray results in his final diagnosis, should I code the findings? The doctor wrote a complete interpretation on the films. He says yes, because usually he has another diagnosis to justify the x-ray.

Virginia Subscriber

Answer: For you to report findings from the x-ray, your orthopedist must document the findings as a final diagnosis. Choosing a diagnosis based on the patient's test results -- even when that diagnosis seems obvious -- is inappropriate and possibly fraudulent coding.

CMS describes its guidelines for this issue in Transmittal AB-01-144 (Sept. 26, 2001) in which the agency states that a physician must confirm a diagnosis based on the test results. If the test results are normal or nondiagnostic, you should code the signs or symptoms that prompted the test. (See www.cms.hhs.gov/transmittals/ Downloads/AB01144.pdf to read the transmittal.)

Similarly, the ICD-9 coding guidelines for diagnostic testing instruct you not to -interpret- what a study says, but rather to rely on the physician's stated diagnosis. If the x-ray findings seem like an important component of the case -- and may play a role in substantiating the medical necessity for the visit -- you should query the physician regarding the diagnosis.

Choose the CPT x-ray code based on anatomy and how many views the physician's office provided. For example, if your office provided a two-view x-ray of a patient's humerus, you would report 73060 (Radiologic examination; humerus, minimum of two views).