Radiology Coding Alert

Learn little-known rules that help with documentation curveballs. Your dream documentation might word every diagnosis to perfectly match an ICD-9 code descriptor. But the reality is that sometimes you have to struggle with too little information on the order or too much information in the findings.  What to do: "Part I: Prove Dx Test Necessity Using 3 CMS-Approved Strategies" in Radiology Coding Alert, Vol. 12, No. 2, presented three key tactics for properly coding diagnostic exams: 1. Base your ICD-9 code on a confirmed diagnosis whenever possible. 2. Choose a "signs and symptoms" code for "normal" tests. 3. Fight the urge to choose a diagnosis based on "uncertain" terms, such as "rule out." Now check out two final strategies to apply when your documentation doesn't offer obvious answers. 1. Take Patient's Word for It ... Rarely At some point, you may hit a snag because the treating physician doesn't offer [...]