Radiology Coding Alert

Smart move: Be sure order documents symptoms before you code them. Don't despair if an X-ray patient's medical record offers only "cough, rule out pneumonia" as a potential diagnosis. Simply take note of these three coding essentials, and you can be sure you're one step closer to choosing the best ICD-9 code for your report. 1. Base ICD-9 on Confirmed Dx When Possible When the radiologist documents a confirmed diagnosis based on the results of the test, you should report that diagnosis, says radiology coding consultant Cheryl A. Schad, BA Ed, CPC, ACS-RA, PCS, of Schad Medical Management in New Jersey in her audioseminar "Radiology Documentation and Ordering Rules" (www.audioeducator.com). For support, Schad cites Medicare Claims Processing Manual (MCPM), Chapter 23, Section 10.1.1, which applies to outpatient/office services (www.cms.hhs.gov/Manuals/IOM/list.asp). Example: A patient presents for an abdominal CT with a "diagnosis" of abdominal pain. The CT reveals an intra-abdominal [...]