Radiology Coding Alert

Read the entire record to identify which unspecified code to use.

Negative findings on a diagnostic test may be a relief to the patient, but can create challenges for proper coding. With a careful review of the ICD-10-CM Official Guidelines, you’ll be ready to properly code screenings and diagnostic tests that have negative results.

Examine three scenarios to understand how to code negative findings listed in the documentation.

Assign Signs and Symptoms Codes When Appropriate

Scenario: A physician orders two-view X-rays of the patient’s left tibia and fibula to evaluate for a fracture. After reviewing the images, the radiologist presents their findings as negative for a fracture.

If the findings are negative, what diagnosis codes do you assign for the encounter? “You would report the signs and symptoms that prompted the provider to order the X-rays,” says Jennifer M. Connell, BA, CPPM, CPCO, CDEO, CPMA, CPB, CRC, COC, CPC, CPC-P, CPC-I, CCC, CCVTC, CEMC, CENTC, CFPC, CGIC, CGSC, CHONC, CUC, ROCC, CEMA, CMCS, CMRS, AAPC-Approved Instructor, revenue cycle director of Citizens Medical Professionals in Victoria, Texas.

Sections IV.D and IV.K of the 2023 ICD-10-CM Official Guidelines provide you with the following guidance:

• IV.D – Codes that describe symptoms and signs
  “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider.”
• IV.K – Patients receiving diagnostic services only
  “For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit.”

In this scenario, you’ll want to review the medical record for any documented signs or symptoms the patient may have been experiencing at the time of the encounter. For example, if the patient’s chief complaint was severe lower leg pain, then you’d assign M79.662 (Pain in left lower leg).

Don’t Forget About Encounter Codes for Screening Exams

Scenario: A patient with a family history of breast cancer presents for her annual screening mammography. The patient is asymptomatic and the screening results are negative for any abnormalities.

To accurately code this encounter, you’ll need to reference the Z codes of the ICD-10-CM code set. “Z codes are appropriate in this scenario. In this case, you’ll assign Z12.31 [Encounter for screening mammogram for malignant neoplasm of breast] and Z80.3 [Family history of malignant neoplasm of breast],” Connell says.

Once again, the ICD-10-CM Official Guidelines are your friend with key instructions on how to code screenings and history (of) conditions. Section I.C.21.c.5, Screening, instructs that a screening code, such as Z12.31, may be a “first-listed code if the reason for the visit is specifically the screening exam.”

A review of section I.C.21.c.4, History (of), indicates that family history codes can be assigned when the patient’s family member(s) had a certain disease, such as breast cancer, which causes the patient to be at greater risk of contracting the disease, as well. The section continues to direct you to assign the appropriate personal and family history codes as additional diagnoses following the reason for the encounter, which is the screening in this case.

Get Specific With Unspecified Codes

Scenario: A patient presents to their physician with low back pain, and the physician orders a computed tomography (CT) scan of the patient’s lumbar spine. The imaging results are negative for fractures, herniated discs, and tumors. The ordering physician documented “pain” as the reason for the imaging examination.

While it may seem tempting to assign R52 (Pain, unspecified) for the provider’s documentation of “pain” in the medical report, the code is incorrect. “Code R52, for unspecified pain, would be rejected by most payers for lack of specificity and medical necessity,” Connell adds. Instead, you’ll need to assign a code or multiple codes that accurately represent the patient’s condition at the time of the encounter.

ICD-10-CM Official Guidelines, section I.B.18, Use of Sign/Symptom/Unspecified Codes, includes a helpful reminder:

• “The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

“It’s not uncommon for a coder to become accustomed to referencing a diagnostic test order for the clinical indication in the absence of a definitive diagnosis. However, we aren’t limited to the order. ICD-10-CM directs us to review the ‘entire record,’” Connell says.

If the radiologist documented findings from the CT scan, you would obviously assign a code reflecting those findings. In this scenario, the physician ordered a CT scan because of the patient’s low back pain, not just unspecified pain. The Official Guidelines instruct that “Each healthcare encounter should be coded to the level of certainty known for that encounter.”

“If the documentation in the scenario reflects that the provider is ordering the CT scan to further evaluate the patient’s presenting symptom of ‘low back pain,’ it would be appropriate for the coder to assign a diagnosis of M54.50 (Low back pain, unspecified),” Connell says.

Excludes1 note: Code R52 features an Excludes1 note in the tabular list that instructs you to choose a specific code for pain if the site is known. Code M54.5- (Low back pain) is included on this Excludes1 list of codes.

There may be times when the documentation is unclear as to why the provider is ordering a CT scan of the lumbar spine. For example, the physician may be managing multiple problems that would necessitate the diagnostic exam, and you might need assistance determining which condition to code.

“This would also be an excellent opportunity to educate the clinician on the importance of documenting to support the highest level of specificity and documentation consistency (e.g., diagnostic test orders should be consistent with the medical record),” Connell adds.