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Radiology Coding Alert

ICD-10-CM Coding:

Streamline Diagnosis Coding Processes With Tricks of the Trade

Published on Mon Mar 22, 2021

When in doubt, always query your providers.

Continuing your evolution as an ICD-10-CM coder means doing more than just staying up to date on the new code sets and guidelines. Knowing your way around a dictation report is half the battle. And proper communication with your providers can’t hurt, either.

Have a look at a few essential pointers that will instantly enhance your diagnosis coding skills.

Don’t Hesitate to Contact Providers When Necessary

Suppose the physician’s dictation specifically states that the patient has lobar pneumonia, but then the documentation refers to treating bilateral pneumonia, leaving the coder to wonder whether the lobar or bilateral code applies. What should you do?

Solution: “Show the discrepancy in the documentation to the physician; once the answer is clarified, the physician should amend the chart note with the appropriate information,” says Elizabeth Cifers, MBA, MSW, CHC, CPC, of Elizabeth Cifers Consulting, LLC. “If the physician uses a scribe, educating both the physician and scribe is essential,” she adds.

If the dictation report documentation does not provide the highest level of specificity to assign a diagnosis code correctly, show the provider the options in the ICD-10-CM code book, so they can see the dilemma in selecting the correct code, she suggests. “Many physicians have been documenting the same way since residency and fellowship and do not realize the level of specificity that ICD-10-CM requires. Education concerning the problem is key to correcting and preventing future occurrences.”

Important: Don’t be afraid to speak up when there is a question or discrepancy in the documentation, Cifers advises. “Unless someone informs the physician, he or she may not know there is an issue.”

Avoid Suspected Diagnoses

A patient presents with shortness of breath, wheezing, and cough. The radiologist suspects chronic obstructive pulmonary disease (COPD), but doesn’t offer concrete documentation supporting COPD in the impression. What should you do?

Solution: In this case, you should only report the signs and symptoms as they appear in the medical record, which in this case include R06.02 (Shortness of breath), R06.2 (Wheezing), any way to connect this to the last paragraph so it doesn’t linger on the next page?

But if there’s no ambiguity surrounding the COPD diagnoses, you’d instead code for this clinical scenario with a code from the J44.- (Other chronic obstructive pulmonary disease) category. Furthermore, if you come across COPD in the indication or findings, but not the impression, you still may report it as a primary or secondary diagnosis. However, this is the kind of scenario that may require a provider query. There are no standardized rules on diagnosis coding in these kinds of instances since determining which diagnoses qualify as relevant (as opposed to incidental) often means taking all three components of the dictation report into consideration. There are also no objective rules that state that the primary diagnosis must come from the impression (assuming one is listed).

Get to Know Common Acronyms

The physician interprets a computed tomography (CT) scan of a patient who presented with shortness of breath and a cough. For the final diagnosis, the radiologist writes “PAP” in impression. This term is unfamiliar to the coding team, so what should you do?

Solution: In this case, it sounds like the physician has diagnosed the patient with pulmonary alveolar proteinosis, often notated by physicians as “PAP.” These patients find it difficult to take oxygen from the air and exchange carbon dioxide from the blood due to a buildup of proteins and lipids in the patients’ air sacs. When patients present with this condition, they’ll often complain of shortness of breath (R06.02), dyspnea (R06.00), or a cough (R05).

Once you confirm the acronym is correct, you’ll report J84.01 (Alveolar proteinosis) for both primary and secondary presentations. However, alveolar proteinosis can manifest secondarily to lung infection or inhalations of dust such as aluminum. In these instances, you will report the reason for the PAP as the primary diagnosis and J84.01 as a secondary diagnosis.

Practice management: You may want to consider a discussion with any radiologist that frequently includes obscure acronyms, or any sort of lingo that might not be easily decipherable by the coding team. Attempting to standardize dictation reports and medical terminology across radiologists is a practical and efficient way of streamlining coding and billing practices. However, your team should also get to know the most common acronyms that your radiologists use and keep a running list.

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