Review the Documentation for Symptoms When X-rays Are Normal
Question: If there is no medical reason for the X-ray listed in the clinical documentation and the X-ray is normal, can I use a pain code or do I need to research the visit to get a reason for why the radiologist performed the X-ray? Currently, the only diagnosis listed is W19.XXXA, which cannot be used as primary. Florida Subscriber Answer: That is correct: W19.XXXA (Unspecified fall, initial encounter) cannot be listed as the first diagnosis code. According to the ICD-10-CM Official Guidelines, section I.C.20.a.6, “An external cause code can never be a principal (first-listed) diagnosis.” Before you report a pain code, you’ll need to know where the pain is occurring in the patient’s body. For example, you’d use M54.50 (Low back pain, unspecified) for lower back pain, M54.2 (Cervicalgia) for neck pain, R10.0 (Acute abdomen) for stomach pain, or M79.604 (Pain in right leg) for right leg pain. Review the clinical documentation or query the physician to find out what symptoms the patient presented with so you can accurately code the reason for the visit. Additionally, payers like to know when and where the incident that led to the injury took place. Refer to the Y92.- (Place of occurrence of the external cause) code category to specify the location of the fall. Mike Shaughnessy, BA, CPC, Development Editor, AAPC
