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.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 guidelines state 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.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 [...]